Pneumocephalus Following Combined Spinal-Epidural Anesthesia: A Case Report Analysis

Background: Combined spinal-epidural anesthesia (CSEA) is widely used in clinical anesthesia due to its rapid onset, reliable anesthetic effect, and strong controllability. Although advancements in technique have reduced the frequency and severity of common complications, reports of rare and serious complications such as pneumocephalus, remain scarce. Case Report: This article presents a case of pneumocephalus following CSEA in a middle-aged female patient undergoing surgery for an intrauterine space-occupying lesion. The patient experienced severe headache postoperatively, and imaging confirmed the presence of intracranial air. After receiving active symptomatic treatment, the patient recovered and was discharged. Conclusion: This case underscores the importance of adhering to standard anesthesia protocols and increasing awareness of rare CSEA complications, particularly the risk of pneumocephalus. Early recognition and timely management are crucial. There is a need to further enhance training and research in anesthetic procedures to improve clinical anesthesia quality and ensure patient safety.

Analgesic Effect of Combined Spinal-Epidural Anesthesia and its Effect on TNF-α and CRP Levels in Elderly Patients with Hip Fracture During Surgical Treatment

Objective:To observe the analgesic effect of combined spinal and epidural anesthesia on older patients undergoing hip fracture surgery.Method:One hundred and twenty elderly hip fracture surgery patients treated in our hospital from January 2021 to December 2022 were selected and randomly divided into two groups,with 60 cases in the experimental group and 60 in the control group.The experimental group was given combined spinal-epidural anesthesia intervention measures,while the control group was given epidural anesthesia intervention measures.The analgesic effect,tumor necrosis factor-alpha(TNF-α),C-reactive protein(CRP)levels,and other observation indicators were analyzed after anesthesia intervention.Result:After the intervention,the analgesic effect and the evaluation results of the subjects in the experimental group were better than those in the control group(P<0.05);the obtained values of TNF-αand CRP levels in the experimental group were higher than those of the control group(P<0.05).Conclusion:The combined spinal-epidural anesthesia intervention demonstrated positive outcomes.The analgesic effect of patients during surgery and their inflammatory factor levels improved,which makes this intervention worthy of clinical application and promotion.

Dynamics of vascular volume and hemodilution of lactated Ringer’s solution in patients during induction of general and epidural anesthesia

Objective： To investigate the dynamics of vascular volume and the plasma dilution of lactated Ringer＇s solution in patients during the induction of general and epidural anesthesia. Methods： The hemodilution of i.v. infusion of 1000 ml of lactated Ringer＇s solution over 60 min was studied in patients undergoing general （n=31） and epidural （n= 22） anesthesia. Heart rate, arterial blood pressure and hemoglobin （Hb） concentration were measured every 5 rain during the study. Surgery was not started until the study period had been completed. Results： General anesthesia caused the greater decrease of mean arterial blood pressure （MAP） （mean 15% versus 9%; P〈0.01） and thereby followed by a more pronounced plasma dilution, blood volume expansion （VE） and blood volume expansion efficiency （VEE）. A strong linear correlation between hemodilution and the reduction in MAP （r=-0.50;P〈0.01） was found. At the end of infusion, patients undergoing general anesthesia retained 47% （SD 19%） of the infused fluid in the circulation, while epidural anesthesia retained 29% （SD 13%） （P〈0.001）. Correspondingly, a fewer urine output （mean 89 ml versus 156 ml; P〈0.05） and extravascular expansion （454 ml versus 551 ml; P〈0.05） were found during general anesthesia. Conclusion： We concluded that the induction of general anesthesia caused more hemodilution, volume expansion and volume expansion efficiency than epidural anesthesia, which was triggered only by the lower MAP.

Dural puncture epidural technique provides better anesthesia quality in repeat cesarean delivery than epidural technique:Randomized controlled study

BACKGROUND Repeat cesarean deliverys involve a longer surgery and more severe visceral traction than primary cesarean deliverys.The dural puncture epidural(DPE)technique provides faster and more effective analgesia for labor,but there is no sufficient evidence to indicate whether it is suitable for parturients undergoing repeat cesarean delivery.AIM To determine the efficacy and safety of the DPE anesthesia technique in patients undergoing repeat cesarean delivery.METHODS Patients undergoing repeat cesarean delivery were randomly divided into the DPE and epidural anesthesia(EA)groups.A 25-G spinal needle was used for dural puncture via a 19-G epidural needle.The patients in the two groups were injected with 5 mL of 2%lidocaine followed by 15 mL of a mixture of 1%lidocaine+0.5%ropivacaine as the epidural dosage.The primary outcome was the onset time of sensory block to the T6 dermatome level and the sensory and motor block degree.RESULTS A total of 115 women were included(EA:57,DPE:58).The mean time to sensory block to the T6 Level was significantly shorter in the DPE group than in the EA group(14.7 min vs 16.6 min;95%confidence interval,13.9 to 15.4 vs 15.8 to 17.4;P=0.001).The cranial sensory block level was significantly higher at 5,10,and 15 min after the initial dose in the DPE group than in the EA group(P<0.05).The sacral sensory block level was significantly higher and the modified bromage score was significantly lower in the DPE group at each time point(P<0.05).Adverse effects and neonatal outcomes were comparable between the two groups(P>0.05).CONCLUSION The DPE technique provided higher-quality anesthesia than the EA technique,with a rapid onset of surgical anesthesia,better cranial and sacral sensory block spread and a higher motor block degree,without increasing the incidence of maternal or fetal side effects in patients undergoing repeat cesarean delivery.

Nonintubated video-assisted thoracic surgery under epidural anesthesia—Encouraging early results encourage randomized trials

Nonintubated video-assisted thoracic surgery （VATS） that is also defined awake VATS entails thoracoscopic procedures performed by regional anesthesia in spontaneously ventilating,mildly sedated or fully awake patients.

Awake thoracoscopic surgery under epidural anesthesia: is it really safe?

Thoracoscopic surgeries usually require single-lung ventilation under general anesthesia because of the need to obtain a sufficient working space.In patients with impaired pulmonary function,if the patient can undergo general anesthesia,a more selected collapse of the lung is considered to be beneficial for intraoperative oxygenation.The selective bronchial blockade of the lobe to be resected has been reported by several investigators （1-3）.Mukaida and coworkers first reported thoracoscopic surgery for pnenmothorax under local and epidural anesthesia in 1998 in high-risk patients contraindicated for general anesthesia （4）.

Comparative Study between General Anesthesia versus General Anesthesia Combined with Thoracic Epidural Analgesia on Cytokine Response in Laparoscopic Cholecystectomy Patients

Background and Objectives: The main benefits of laparoscopic surgery in comparison to open surgery involve the rapid discharge from recovery room, decreased postoperative hospital stays, reduced postoperative discomfort, easier getting back to work and faster return to ordinary daily life as well as cosmetic surgical wounds. The anesthesia type has an essential role in attenuation of the surgical stress and achievement of these advantages. We aimed to determine the outcome of giving general anesthesia in conjunction with thoracic epidural analgesia (TEA) compared to general anesthesia alone on stress response to surgery and anesthesia by investigating cytokine reaction (interleukin 6 and 8 levels), hemodynamic changes (BP, HR, RR, SPO2), and Visual Analogue Scale (VAS) scores postoperatively in patients subjected for laparoscopic cholecystectomy. Methods: This study included 40 patients aged 20 - 60 years old with American Society of Anesthesiologists physical status (ASA) I and II. They were planned for laparoscopic cholecystectomy at Aswan University Hospital from April 2017 to March 2018. They were randomly allocated into two groups. Group A (n. 20) received general anesthesia only and Group B (n. 20) received general anesthesia in conjunction with thoracic epidural analgesia using fentanyl and bupivacaine in the epidural catheter. Chi-square was applied to differentiate categorical variables, whereas comparison between continuous variables was done by using t-test. Two-tailed p < 0.05 was estimated as statistically significant. Results: As regards IL-6 and IL-8 post-operative there is significant difference (p < 0.05) between two groups during 2nd and 4th hr and 24th hr postoperative, with significantly increased postoperative levels of IL-6 and IL-8 in comparison to their preoperative baseline values. The largest increase in IL6 & IL8 levels was in group A (GA group). VAS score showed significant lower values in TEA group in comparison to GA group. No significant difference between groups as regard intraoperative and postoperative hemodynamic changes. Conclusion: Regional techniques including TEA attenuate and decrease cytokine reaction secondary to surgery which decreases inflammatory process and improves patient outcome and reduces pain score postoperatively.

SUMMARY OF CLINICAL STUDY ON ACUPUNCTURE COMBINED WITH EPIDURAL ANESTHESIA FOR CHOLECYSTECTOMY

Objective: TO study clinical effect and anesthetic method of acupuncture anesthesia combined with epidural administration of small dose of anesthetic for cholecystectomy. Methods: A total of 194 cases of cholecystectomy patients were randomly divided into acupuncture combined with epidural anesthesia group (group A, n = 66), acupoint-skin electrical stimulation combined with epidural anesthesia group (group B, n = 63) and simple epidural anesthesia group (group C, n=65). Observations were conducted using single-bland method. Bilateral Neiguan (PC 6) and Zusanli (ST 36) were punctured and stimulated electrically in group A and only stimulated electrically via cutaneous electrodes in group B. Epidural anesthetic used was 1.5% Lidocaine and the anesthetic level was controlled to reach T4-11 . Results: The class-I (excellent) rates of group A, B and C were 75.76%, 60.32% and 13.85% respectively, showing significant differences between group A and C and group B and C (P <0.001). The initial dose, doses of every hour and every case of group A and B were lower than those of group C. The dose of every hour of group C was 36.23% and 3. 75% higher then group A and B respectively (P < 0. 001), suggesting that acupuncture or acupoint-skin electrical stimulation could strengthen anesthetic effect and reduce the dose of epidural anesthetic. During operation, indexes of the life signs as HR, MAP, RR, TV, MV, SpO2 and ECG kept basically stable and all patients in group A passed surgical operation safely. Conclusion: Acupuncture or acupoint-skin electrical stimulation combined with epidural anesthesia can be used as one of the anesthetic methods for cholecystectomy.

EFFECT OF ACUPUNCTURE COMBINED WITH EPIDURAL ANESTHESIA ON PLASMA CATECHOLAMINE CONTENT IN CHOLECYSTECTOMY PATIENTS

Objective: To observe changes of plasma catecholamine (CA) level in patients experiencing cholecystectomy under acupuncture anesthesia combined with epidural administration of small dose of anesthetics. Methods: 33 cholecystectomy patients were randomly divided into acupuncture combined with epidural anesthesia (A) group (n=11), acupoint skin electrical stimulation combined with epidural anesthesia (B) group (n=11) and simple epidural anesthesia (C) group (n=11). Acupoints used were bilateral Zusanli (ST 36) and Neiguan (PC 6) and stimulated with parameters of frequency 2/15 Hz, intermittent waves, electric current 2～3 mA for group A and 13mA for group B. Extradural anesthetic administered was 1.5% Lidocaine 5 mL. Venous blood samples were collected one day before, during and 3 days after operation for detecting plasma NE, E and DA contents. Results: ① During operation, plasma NE of group A and B lowered in comparison with pre operation, particularly group A (P<0.01), while in group C, plasma NE level increased slightly; plasma E of group A and B increased significantly compared with pre operation (P< 0.01). Plasma DA in the 3 groups all raised during operation. ② Three days after operation, plasma NE, E and DA levels recovered basically in comparison with those of one day before operation. It indicates that acupuncture or acupoint skin electrical stimulation is capable of regulating sympathetic activity during epidural anesthesia. The anesthetic effect has a closer relation with changes of plasma NE level rather than changes of plasma E or DA levels. Conclusion: Acupuncture or acupoint surface electrical stimulation combined with epidural anesthesia may be of reducing or releasing surgical operation generated stress response during cholecystectomy.

Role of epidural anesthesia in a fast track liver resection protocol for cirrhotic patients-results after three years of practice

AIM To evaluate the potential benefits and risks of the use of epidural anaesthesia within an enhanced recovery protocol in this specific subpopulation.METHODS A retrospective review was conducted, including all cirrhotic patients who underwent open liver resection between January 2013 and December 2015 at Bologna University Hospital. Patients with an abnormal coagulation profile contraindicating the placement of an epidural catheter were excluded from the analysis. The control group was composed by patients refusing epidural anaesthesia. RESULTS Of the 183 cirrhotic patients undergoing open liver resections, 57 had contraindications to the placement of an epidural catheter; of the remaining 126, 86 patients received general anaesthesia and 40 combined anaesthesia. The two groups presented homogeneous characteristics. Intraoperatively the metabolic data did not differ between the two groups, whilst the epidural group had a lower mean arterial pressure(P = 0.041) and received more colloid infusions(P = 0.007). Postoperative liver and kidney function did not differ significantly.Length of mechanical ventilation(P = 0.003) and hospital stay(P = 0.032) were significantly lower in the epidural group. No complications related to the epidural catheter placement or removal was recorded.CONCLUSION The use of Epidural Anaesthesia within a fast track protocol for cirrhotic patients undergoing liver resections had a positive impact on the patient's outcomes and comfort as demonstrated by a significantly lower length of mechanical ventilation and hospital stay in the epidural group. The technique appears to be safely manageable in this fragile population even though these results need confirmation in larger studies.

Thoracic epidural anesthesia:Effects on splanchnic circulation and implications in Anesthesia and Intensive care

AIM: To evaluate the currently available evidence on thoracic epidural anesthesia effects on splanchnic macro and microcirculation, in physiologic and pathologic conditions.METHODS:A Pub Med search was conducted using the Me SH database.Anesthesia,Epidural was always the first MeS H heading and was combined by boolean operator AND with the following headings:Circulation,Splanchnic;Intestines;Pancreas and Pancreatitis;LiverFunction Tests.EMBASE,Cochrane library,ClinicalT rials.gov and clinicaltrialsregister.eu were also searched using the same terms.RESULTS:Twenty-seven relevant studies and four ongoing trials were found.The data regarding the effects of epidural anesthesia on splanchnic perfusion are conflicting.The studies focusing on regional macro-hemodynamics in healthy animals and humans undergoing elective surgery,demonstrated no influence or worsening of regional perfusion in patients receiving thoracic epidural anesthesia(TEA).On the other hand most of the studies focusing on micro-hemodynamics,especially in pathologic low flow conditions,suggested that TEA could foster microcirculation.CONCLUSION:The available studies in this field are heterogeneous and the results conflicting,thus it is difficult to draw decisive conclusions.However there is increasing evidence deriving from animal studies,that thoracic epidural blockade could have an important role in modifying tissue microperfusion and protecting microcirculatory weak units from ischemic damage,regardless of the effects on macro-hemodynamics.

Effect of epidural block combined intravenous general anesthesia stress on the stress response and T lymphocyte subsets in patients with breast cancer undergoing radical mastectomy

Objective: To investigate the effect of epidural block combined with intravenous anesthesia on stress response and T lymphocyte subsets in patients with breast cancer undergoing radical mastectomy. Methods: In our hospital from July 2016 to June 2017 undergoing radical mastectomy for breast cancer of 88 patients were randomly divided into observation group and control group of 44 cases, 2 patients underwent routine preoperative preparation, and routine blood pressure, heart rate, pulse, oxygen saturation, ECG monitoring, control group with intravenous anesthesia. The observation group was treated with epidural block combined with intravenous anesthesia. 2 groups of patients before anesthesia, 30 MIM (T0), 1 h after skin incision (T1), 4 h after operation (T2), 24 h after operation (T3), 48 h after operation (T4) from peripheral venous blood were measured by interleukin-8 (IL-8) and interferon gamma (IFN-γ), cortisol (Cor), prolactin (PRL), growth hormone (GH) and T lymphocyte subsets (CD3+, CD4+, CD8+), the calculation of CD4+/CD8+ value. Results: the serum IL-8 level of T1, T2, T3and T4 decreased gradually, were lower than at T0, and the control group at each time point had no significant difference, T1, T2, T3group, T4IL-8 levels lower than the control group;the 2 groups of serum IFN-γ levels T1 and T2had no significant change, T3and T4increased gradually, was higher than that of T0, but no significant difference between the 2 groups of IFN-γ levels. 2 serum Cor levels peaked at T1, decreased at T2, was higher than that of T0, T3, T4returned to T0, the observation group T1, T2Cor level lower than the control group;the serum PRL levels of 2 groups reached a peak at T1, T2, T3at the time of T4decreased gradually, was higher than that of T0, T1, T2, T3of the observation group at the PRL level is lower than the control group;the serum level of GH 2 in group T1increased gradually, reached a peak at T2, T3and T4 decreased gradually, was higher than that of T0, the observation group T1, T2, T3, T4, GH levels lower than the control group. 2 groups of CD3+ decreased gradually in T1, T2, were lower than T0, T3, T4returned to T0, the observation group T1, T2CD3+ was higher than the control group;group CD4+ decreased gradually in T1, T2, T3and T4were lower than control, T0when, and the observation group CD4+ in T1, T2, T3, T4, no significant changes were observed in group T1, T2, T3, T4and CD4+ higher than that of the control group;the 2 group CD8+ had no obvious changes in T1, T2, T3, T4;observation group CD4+/CD8+ decreased gradually in T1, T2, were lower than T0, T3, T4returned to T0, the observation group T1, T2CD4+/CD8+ was higher than the control group. Conclusion: epidural block combined with intravenous anesthesia for breast cancer radical mastectomy can effectively relieve the stress and inflammatory reaction, alleviate the immunosuppression, and help to restore the postoperative immune function.

A CLINICAL STUDY ON THE SUBTOTAL GASTRECTOMY UNDER ACUPUNCTURE COMBINED WITH EPIDURAL ANESTHESIA OF SMALL DOSAGE

We have performed operations on the patients with perforation of gastric ulcer forsubtotal gastrectomy under acupuncture combined with epidural anesthesia of smaIl dosage （studygroup） or epidural anesthesia only（control gr0up） at rand0m, 2O cases in each group. There is no ob-vious difference of successful rates between tw0 groups （P】O. O5）. But the fluctuation of the bloodpressure of the study group is smaller than that of the control group（PwtO- O1 ）; the comparison of thefluctuations of capacity of vessel and the changes 0f TMwave of ECG before and during operationshows that the study group is better than control gr0up （PrO. O1, P【O. O5, respectively）; in thestudy group, WBC is decreased significantly after operation, while in the control guoup, CRP（C-re-active pr0tein） is markedIy increased, there are significant differences of these indices between twogroups（P【0. 05, respectively）; complement C3, IgA, IgG and IgM are decreased to a different ex- tent after operation in both groups, but the

Pregnant women’s awareness and acceptance of epidural anesthesia and its influence on cesarean section rate control in China: A qualitative study

Background: Epidural anesthesia, as an effective pain relief method, could be viewed as an attempt to encourage vaginal delivery and control cesarean section. Increased demand caused by psychosocial factors such as fear of childbirth and labor pain is supposed to be one predictable drive of high cesarean section rate in present China. Little qualitative information on women’s awareness and perceptions of epidural anesthesia was found, but conscious efforts should be focused on this part to help generate policy-making priority. Methods: This study was carried out under an exploratory descriptive design in Bao’an Maternity and Child Health Hospital. Those interested in participating would be invited to focus group discussion or individual interview according to a semi-structured open-ended guide after collecting the participants’ demographic characteristics. The thematic content analysis approach was used for data analysis. Results: Five major themes were identified: 1. the sources to gain information on epidural anesthesia;2. clinical impact;3. social impact on awareness;4. association between epidural anesthesia and cesarean section;5. attitudes and questions about the current service implementation. Discussions: The interplay between pregnancy knowledge, socio-economic conditions, social support, insurance policy environment, women’s judgment of health care quality influences the ways women acknowledge and utilize epidural anesthesia service. Conclusions: As maternal requested CS due to low pain tolerance emerges gradually, natural labor with epidural anesthesia is a more suitable childbirth option, which is also expected to function in reducing CS rate by service-providers and administrators in the health departments of China besides building up a pain-free labor environment.

Case Report: Rare Presentations of Accidental Subdural Block in Labor Epidural Anesthesia

The incidence of accidental injection or catheterization of the subdural space during performance of a neuroaxial block has recently increased. It can occur even when an experienced practitioner performs the neuraxial procedure. The presentation of numerous unexplainable clinical signs in the process of continuous epidural anesthesia, which do not fit the clinical picture of subarachnoid or intravascular injection, should envoke a high suspicion for unintentional subdural block. We report two cases of patients who achieved prolonged labor analgesia via epidural technique with only half the initial loading dose of local anesthetic. Both patients also had short episodes of hypotension. Additionally, one patient presented with severe hypoxemia and mild motor block of both upper and lower extremities. The other patient presented with transit unresponsiveness without motor block. Both patients rapidly responded to vasopressors. Desaturation in one patient, however, was persistent lasting for more than four hours. Her bedside chest X-ray was inconclusive “possible pulmonary edema” and the follow up Chest CT Scan on the second day revealed aspiration pneumonia. Based on the clinical findings, these two cases were suggestive of subdural block with cranial nerve involvement.

A REPORT ON ONE CASE OF CURED PARAPLEGIA INDUCED BY EPIDURAL ANESTHESIA

Chen Suqin,female,39 years old. Patient’s condition and process of diagnosesand treatment:The patient was hospitalized atthe Department of Gynecology in our hospitalowing to right hydrosalpinx.At 9 o’clock onJuly 22,1992,the right hydrosalpinx of patient（would be）excised under continuous epiduralanesthesia.Owing to failure of epidural anesthesia in operation,general anesthesia was used tofinish the operation.At that night of operationand the next day,the patient got out of bed

A Structured Method of Teaching Epidural Block reduces the incidence of accidental dural puncture in inexperienced trainees.

Background: The rate of accidental dural puncture is particularly high during the period of training, especially in novices. The structured epidural teaching model (SETM) includes three standardized video lessons, the construction of a 3D epidural module by trainees and practical training by using an epidural simulator with and without the CompuFlo™ Epidural instrument. In this study we report the retrospective analysis of the accidental dural puncture rate of inexperienced trainees during their 6 months clinical practice rotation in obstetrics before and after the introduction of the SETM in our Institution. Method: We evaluated the incidence of accidental dural puncture before the introduction of the SETM methodology and afterwards by analyzing our departmental database from February 2019 to January 2023. All epidural blocks were executed by trainees who had never previously performed an epidural block and were about to begin their obstetrics rotation. Results: We analyzed 7415 epidurals: 3703 were performed before the introduction of the SETM methodology (control group) and 3712 afterwards (study group). The incidence of accidental dural puncture was 0.37% for the control group and 0.13% for the study group (p<.05). The probability of making an accidental dural puncture was 64% (OR: 0.36) lower for trainees who had the training than for those who did not. Conclusions: After the introduction of the structured teaching method, we observed a significant reduction of accidental dural puncture during the training period. We hope that our observation will encourage a constructive discussion among experts about the need to use standardized and validated tools as a valuable aid in teaching epidural anesthesia.

The Regulation Action of Electric Acupuncture Neiguan on Arrhythmia under the Epidural Anesthesia

There were 82 gynopathic operation cases in which we used electric acupuncture（50—100 Hz）inNeiguan（PC 6）on the two sides during the operation with the continuous epidural anesthesia becausein those patients there were abnormal ECGs before the operation such as sinus tachycardia,sinusbradycardia,accidental of frequent ventricuar premature beat,artrial premature beat,Ⅰdegree or Ⅱdegrees atrioventricular heartblock,double bundle-branch heart-block,low voltage in

Peripheral Nerve Block Combined with Epidural Anesthesia for Incarcerated Inguinal Hernia Repair in a Patient with Severe Chronic Obstructive Pulmonary Disease: A Case Report

Background: Invasive mechanical ventilation worsens prognosis in patients with severe chronic obstructive pulmonary disease (COPD). To avoid complications in these patients, anesthesia should be carefully considered. Case presentation: A 78-year-old man with COPD presented with dyspnea and pain from the epigastric to the umbilical regions. He was diagnosed with left incarcerated inguinal hernia and underwent radical inguinal hernia repair and surgical ileus treatment. To avoid general anesthesia with tracheal intubation, epidural anesthesia was combined with peripheral nerve blocks. An epidural catheter was inserted from T12/L1, and ilioinguinal-iliohypogastric and genitofemoral nerve blocks were performed under ultrasound guidance. No post-surgery complications or pain symptoms were noted. Conclusions: General anesthesia would likely have been challenging due to the patient’s COPD;however, management of peritoneal traction pain is difficult using peripheral nerve block alone. By combining epidural anesthesia with peripheral nerve blocks, we safely performed a procedure in a patient with severe COPD while avoiding invasive positive pressure ventilation.