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      Procedural Complications of Spinal Anaesthesia in the Obese Patient

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          Background. Complications of spinal anaesthesia (SpA) range between 1 and 17%. Habitus and operator experience may play a pivotal role, but only sparse data is available to substantiate this claim. Methods. 161 patients were prospectively enrolled. Data such as spread of block, duration of puncture, number of trials, any complication, operator experience, haemodynamic parameters, was recorded and anatomical patient habitus assessed. Results. Data from 154 patients were analyzed. Success rate of SpA in the group of young trainees was 72% versus 100% in the group of consultants. Trainees succeeded in patients with a normal habitus in 83.3% of cases versus 41.3% when patients had a difficult anatomy (P = 0.02). SpA in obese patients (BMI ≥ 32) was associated with a significantly longer duration of puncture, an increased failure ratio when performed by trainees (almost 50%), and an increased number of bloody punctures. Discussion. Habitus plays a pivotal role for SpA efficiency. In patients with obscured landmarks, failure ratio in unexperienced operators is high. Hence, patient prescreening as well as adequate choice of operators may be beneficial for the success rate of SpA and contribute to less complications and better patient and trainee satisfaction.

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          Post-dural puncture headache: pathogenesis, prevention and treatment.

          Spinal anaesthesia developed in the late 1800s with the work of Wynter, Quincke and Corning. However, it was the German surgeon, Karl August Bier in 1898, who probably gave the first spinal anaesthetic. Bier also gained first-hand experience of the disabling headache related to dural puncture. He correctly surmised that the headache was related to excessive loss of cerebrospinal fluid (CSF). In the last 50 yr, the development of fine-gauge spinal needles and needle tip modification, has enabled a significant reduction in the incidence of post-dural puncture headache. Though it is clear that reducing the size of the dural perforation reduces the loss of CSF, there are many areas regarding the pathogenesis, treatment and prevention of post-dural puncture headache that remain contentious. How does the microscopic pattern of collagen alignment in the spinal dura affect the dimensions of the dural perforation? How do needle design, size and orientation influence leakage of CSF through the dural perforation? Can pharmacological methods reduce the symptoms of post-dural puncture headache? By which mechanism does the epidural blood patch cure headache? Is there a role for the prophylactic epidural blood patch? Do epidural saline, dextran, opioids and tissue glues reduce the rate of CSF loss? This review considers these contentious aspects of post-dural puncture headache.
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            Learning manual skills in anesthesiology: Is there a recommended number of cases for anesthetic procedures?

            The learning process is a multidimensional function with a wide intra- and interindividual scattering. To determine the learning process in anesthesia, we evaluated 11 first-year residents according to their rate of success or failure when applying manual anesthesiological skills, such as performance of spinal, epidural, or brachial plexus anesthesia and tracheal intubation or insertion of an arterial line. Epidural anesthesia was the most difficult procedure (P < 0.05). Significant differences were found between epidural anesthesia and tracheal intubation (P < 0.05), insertion of an arterial line (P < 0.05), and brachial plexus block (P < 0.05), as well as between spinal anesthesia and orotracheal intubation (P < 0.05). Learning curves are a valid tool for monitoring institutional and individual success. To investigate the learning process in anesthesia, typical anesthetic procedures were performed by inexperienced residents during their first year. Learning curves were generated for each procedure performed. Epidural anesthesia was the most difficult procedure to perform (P < 0.05).
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              Failed spinal anaesthesia: mechanisms, management, and prevention.

              Although spinal (subarachnoid or intrathecal) anaesthesia is generally regarded as one of the most reliable types of regional block methods, the possibility of failure has long been recognized. Dealing with a spinal anaesthetic which is in some way inadequate can be very difficult; so, the technique must be performed in a way which minimizes the risk of regional block. Thus, practitioners must be aware of all the possible mechanisms of failure so that, where possible, these mechanisms can be avoided. This review has considered the mechanisms in a sequential way: problems with lumbar puncture; errors in the preparation and injection of solutions; inadequate spreading of drugs through cerebrospinal fluid; failure of drug action on nervous tissue; and difficulties more related to patient management than the actual block. Techniques for minimizing the possibility of failure are discussed, all of them requiring, in essence, close attention to detail. Options for managing an inadequate block include repeating the injection, manipulation of the patient's posture to encourage wider spread of the injected solution, supplementation with local anaesthetic infiltration by the surgeon, use of systemic sedation or analgesic drugs, and recourse to general anaesthesia. Follow-up procedures must include full documentation of what happened, the provision of an explanation to the patient and, if indicated by events, detailed investigation.

                Author and article information

                1Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Albert-Schweitzer Campus 1, A1, 48149 Muenster, Germany
                2Medical School, University of Muenster, 48149 Muenster, Germany
                3Department of Anesthesiology and Intensive Care, St. Franziskus Hospital, 48145 Muenster, Germany
                Author notes

                Academic Editor: Michael R. Frass

                Anesthesiol Res Pract
                Anesthesiol Res Pract
                Anesthesiology Research and Practice
                Hindawi Publishing Corporation
                30 July 2012
                : 2012
                Copyright © 2012 Manuel Wenk et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Clinical Study

                Anesthesiology & Pain management


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