Significance of Expiratory Muscle Strength in Gynecologic Patients after Spinal Anesthesia

Background: The spinal block has become a favorable technique for gynecologic surgery. However, the level of sympathetic blockade results in weak diaphragm and respiratory muscles as well as cough impairment. Investigators were curious to assess patients’ respiratory functions after spinal anesthesia. Materials and Methods: One hundred forty-five gynecologic patients undergoing elective, exploratory laparotomy with spinal anesthesia were included. The blowing practice of a Mini Wright Peak Flow Meter was performed until patients became comfortable with it. A given patient blew the device three times, and the best value was chosen to assess peak expiratory flow rates (PEFRs): prior to surgery (P1), after the spinal block (P2), and in the recovery room (P3). Results: At the thoracic blockade level as T was 4 or less and T was greater than 4, PEFR at P1, P2 and P3 were 285.9±5.9, 222.3±4.9, and 216.4±6.4 mL, and 302.8±7.7, 224.9±6.4, and 203.4±8.4 mL, respectively. The PEFRs showed no significant differences among the levels of blockade at the ward (p=0.082), the operating theater (p=0.744), and the recovery room (p=0.211). Though P3 seemed to fall, there was no marked difference between P2 and P3 (p=0.224). However, either P2 or P3 appeared to decrease sharply (p<0.001) in comparison with P1. Conclusion: A Mini Wright Peak Flow Meter can be used as a bedside device to measure PEFRs. The substantial decrease of PEFR was related to the level of sympathetic blockade after spinal anesthesia. Keywords: Anesthesia, Spinal block, Peak expiratory flow rate, Gynecology

Crystalloids versus colloids versus hypertonic saline co-load during spinal anesthesia: which is more effective?

Spinal anesthesia is very commonly accompanied by hypotension due to sympathetic blockade, which leads to vasodilation. There is an ongoing debate concerning pre-load versus co-load and also the best suitable type of fluid to be given, including hypertonic saline (HS). We conducted this study to compare the efficacy of the three solutions, crystalloids vs. colloids vs. hypertonic saline co-load during spinal anesthesia.

Local Sympathectomy Promotes Anti-inflammatory Responses and Relief of Paclitaxel-induced Mechanical and Cold Allodynia in Mice

Background Patients undergoing cancer treatment often experience chemotherapy-induced neuropathic pain at their extremities, for which there is no U.S. Food and Drug Administration–approved drug. The authors hypothesized that local sympathetic blockade, which is used in the clinic to treat various pain conditions, can also be effective to treat chemotherapy-induced neuropathic pain. Methods A local sympathectomy (i.e., cutting the ipsilateral gray rami entering the spinal nerves near the L3 and L4 dorsal root ganglia) was performed in mice receiving intraperitoneal injections every other day of the chemotherapeutic drug paclitaxel. Sympathectomy effects were then assessed in chemotherapy-induced pain-like behaviors (i.e., mechanical and cold allodynia) and neuroimmune and electrophysiologic responses. Results Local microsympathectomy produced a fast recovery from mechanical allodynia (mean ± SD: sympathectomy vs. sham at day 5, 1.07 ± 0.34 g vs. 0.51 ± 0.17g, n = 5, P = 0.030 in male mice, and 1.08 ± 0.28 g vs. 0.62 ± 0.16 g, n = 5, P = 0.036 in female mice) and prevented the development of cold allodynia in both male and female mice after paclitaxel. Mechanistically, microsympathectomy induced transcriptional increases in dorsal root ganglia of macrophage markers and anti-inflammatory cytokines, such as the transforming growth factor-β. Accordingly, depletion of monocytes/macrophages and blockade of transforming growth factor-β signaling reversed the relief of mechanical allodynia by microsympathectomy. In particular, exogenous transforming growth factor-β was sufficient to relieve mechanical allodynia after paclitaxel (transforming growth factor-β 100 ng/site vs. vehicle at 3 h, 1.21 ± 0.34g vs. 0.53 ± 0.14 g, n = 5, P = 0.001 in male mice), and transforming growth factor-β signaling regulated neuronal activity in dorsal root ganglia. Conclusions Local sympathetic nerves control the progression of immune responses in dorsal root ganglia and pain-like behaviors in mice after paclitaxel, raising the possibility that clinical strategies already in use for local sympathetic blockade may also offer an effective treatment for patients experiencing chemotherapy-induced neuropathic pain. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Perbandingan Pemberian Cairan Koloid Co-loading dengan Infus Efedrin terhadap Pencegahan Hipotensi akibat Anestesi Spinal pada Seksio Sesarea

Latar Belakang: Hipotensi merupakan komplikasi anestesi spinal pada seksio sesarea karena blokade simpatis akibat vasodilatasi arteri dan vena. Pemberian koloid co-loading dapat meningkatkan volume intravaskular sedangkan infus efedrin diharapkan terjadi vasokonstriksi. Tujuan: Untuk membandingkan pemberian efedrin dan cairan koloid co-loading dalam mencegah hipotensi akibat anestesi spinal pada seksio sesarea. Metode: Uji terkontrol acak buta tunggal pada 42 pasien seksio sesarea dengan anestesi spinal yang dilakukan di Rumah Sakit Hasan Sadikin Bandung pada September sampai Oktober 2018. Subjek penelitian dibagi secara acak menjadi 2 kelompok yaitu kelompok pemberian infus efedrin dan kelompok pemberian koloid secara co-loading. Kelompok koloid diberikan cairan koloid sebanyak 7 mL/KgBB selama 20 menit sedangkan kelompok efedrin diberikan efedrin bolus 5 mg pada menit pertama dan kedua, kemudian 15 mg dalam infus selama 15 menit. Tekanan darah diukur setiap 1 menit selama 10 menit, kemudian setiap 3 menit sampai menit ke-45. Analisis statistik yang digunakan adalah uji T tidak berpasangan dan Mann Whitney. Hasil: penelitian menunjukan angka kejadian hipotensi lebih sedikit pada kelompok infus efedrin (5/21) dibandingkan dengan kelompok koloid (15/21) dengan perbedaan yang bermakna (p<0,05). Simpulan: penelitian ini menunjukan bahwa kejadian hipotensi pada pasien seksio sesarea yang dilakukan anestesi spinal lebih banyak pada kelompok koloid co-loading dibandingkan dengan kelompok infus efedrin. Comparison of Colloid Co-loading with Ephedrine Infusion on Prevention of Hypotension Due to Spinal Anesthesia in Cesarean Section Abstract Background: Hypotension is a complication of spinal anesthesia in cesarean section due to sympathetic blockade that causes arterial and venodilation. Administration co-loading of colloid can increase intravascular volume, whereas administration of ephedrine infusion expected to vasoconstric. Objective: To compare administration of co-loading colloid with ephedrine infusion on preventing hypotension due to spinal anesthesia in cesarean section. Method: A single blind randomized controlled trial in 42 patients who underwent cesarean section under spinal anesthesia, the physical status of ASA II which was randomly divided into 2 group administering ephedrine infusion and colloid co-loading. Colloid was given 7 ml/ Kg for 20 minutes, whereas ephedrine bolus 5 mg was given in the first and second minutes, then 15 mg in infusion for 15 minutes. Blood pressure is measured every 1 minute for 10 minutes, then every 3 minutes until the 45th minute. the statistical analysis used is unpaired T test and Mann Whitney. Results: The study showed a lower incidence of hypotension in the ephedrine infusion group (5/21) compared with the colloid group (15/21), this difference was statistically significant (p <0.05). Conclusions: This study show that the incidence of hypotension in cesarean section patients was more in the colloid group compared to the ephedrine group.

Manejo anestésico de la tormenta arrítmica mediante bloqueo simpático

La tormenta arrítmica se define por la presencia de tres o más episodios de taquicardia ventricular, fibrilación ventricular y/o descargas de un desfibrilador automático implantable (DAI) en un periodo de 24 horas. En su manejo es esencial la identificación y corrección de factores desencadenantes, como isquemia miocárdica, alteraciones hidroelectrolíticas, descompensación de la insuficiencia cardíaca, así como el adecuado control del tono simpático. Presentamos el caso de un varón de 43 años con miocardiopatía hipertrófica apical, portador de DAI en prevención primaria que ingresa por tormenta arrítmica de difícil control farmacológico y ablación ineficaz, con repercusión clínica importante. Ante posible componente de descarga adrenérgica, se decide implante de catéter epidural alto alcanzándose bloqueo simpático con perfusión de lidocaína y reducción de los episodios arrítmicos. Posteriormente se realizó simpatectomía bilateral torácica con evolución favorable. ABSTRACT Anaesthetic management of arrhythmic storm by sympathetic block The arrhythmic storm is defined by the presence of three or more episodes of ventricular tachycardia, ventricular fibrillation and / or discharges of an implantable cardioverter defibrillator (ICD) in a 24-hour period. In its management, the identification and correction of triggering factors is essential, such as myocardial ischemia, hydroelectrolyte alterations, decompensation of heart failure, as well as the adequate control of sympathetic tone. We present the case of a 43-year-old man with apical hypertrophic cardiomyopathy, carrier of ICD in primary prevention who arrives due to an arrhythmic storm with difficult pharmacological control and ineffective ablation, with important clinical repercussions. Before possible component of adrenergic discharge, it was decided to implant a high epidural catheter reaching sympathetic blockade with lidocaine perfusion and reduction of arrhythmic episodes. Subsequently, bilateral thoracic sympathectomy with favorable evolution was performed.