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Preclinical data suggest that general anaesthetics affect brain development. There is mixed evidence from cohort studies that young children exposed to anaesthesia can have an increased risk of poor neurodevelopmental outcome. We aimed to establish whether general anaesthesia in infancy has any effect on neurodevelopmental outcome. Here we report the secondary outcome of neurodevelopmental outcome at 2 years of age in the General Anaesthesia compared to Spinal anaesthesia (GAS) trial. In this international assessor-masked randomised controlled equivalence trial, we recruited infants younger than 60 weeks postmenstrual age, born at greater than 26 weeks' gestation, and who had inguinal herniorrhaphy, from 28 hospitals in Australia, Italy, the USA, the UK, Canada, the Netherlands, and New Zealand. Infants were randomly assigned (1:1) to receive either awake-regional anaesthesia or sevoflurane-based general anaesthesia. Web-based randomisation was done in blocks of two or four and stratified by site and gestational age at birth. Infants were excluded if they had existing risk factors for neurological injury. The primary outcome of the trial will be the Wechsler Preschool and Primary Scale of Intelligence Third Edition (WPPSI-III) Full Scale Intelligence Quotient score at age 5 years. The secondary outcome, reported here, is the composite cognitive score of the Bayley Scales of Infant and Toddler Development III, assessed at 2 years. The analysis was as per protocol adjusted for gestational age at birth. A difference in means of five points (1/3 SD) was predefined as the clinical equivalence margin. This trial is registered with ANZCTR, number ACTRN12606000441516 and ClinicalTrials.gov, number NCT00756600. Between Feb 9, 2007, and Jan 31, 2013, 363 infants were randomly assigned to receive awake-regional anaesthesia and 359 to general anaesthesia. Outcome data were available for 238 children in the awake-regional group and 294 in the general anaesthesia group. In the as-per-protocol analysis, the cognitive composite score (mean [SD]) was 98·6 (14·2) in the awake-regional group and 98·2 (14·7) in the general anaesthesia group. There was equivalence in mean between groups (awake-regional minus general anaesthesia 0·169, 95% CI −2·30 to 2·64). The median duration of anaesthesia in the general anaesthesia group was 54 min. For this secondary outcome, we found no evidence that just less than 1 h of sevoflurane anaesthesia in infancy increases the risk of adverse neurodevelopmental outcome at 2 years of age compared with awake-regional anaesthesia. Australia National Health and Medical Research Council (NHMRC), Health Technologies Assessment-National Institute for Health Research UK, National Institutes of Health, Food and Drug Administration, Australian and New Zealand College of Anaesthetists, Murdoch Childrens Research Institute, Canadian Institute of Health Research, Canadian Anesthesiologists' Society, Pfizer Canada, Italian Ministry of Heath, Fonds NutsOhra, and UK Clinical Research Network (UKCRN).

BackgroundThis systematic review examines the evidence for preprocedural neuraxial ultrasound as an adjunct to lumbar spinal and epidural anesthesia in adults.MethodsWe searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from inception to June 30, 2014, for randomized controlled trials (RCTs) and cohort studies that reported data answering one or more of the following 3 questions: (1) Does ultraound accurately identify a given lumbar intervertebral space? (2) Does ultrasound accurately predict the needle insertion depth required to reach the epidural or intrathecal space? (3) Does ultrasound improve the efficacy and safety of spinal or lumbar epidural anesthesia?ResultsThirty-one clinical trials and 1 meta-analysis were included in this review. Data from 8 studies indicate that neuraxial ultrasound can identify a given lumbar intervertebral space more accurately than by landmark palpation alone. Thirteen studies reported an excellent correlation between ultrasound-measured depth and needle insertion depth to the epidural or intrathecal space. The mean difference between the 2 measurements was within 3 mm in most studies. Thirteen RCTs, 5 cohort studies, and 1 meta-analysis reported data on efficacy and safety outcomes. Results consistently showed that ultrasound resulted in increased success and ease of performance. Ultrasound seemed to reduce the risk of traumatic procedures but there was otherwise insufficient evidence to conclude if it significantly improves safety.ConclusionsThere is significant evidence supporting the role of neuraxial ultrasound in improving the precision and efficacy of neuraxial anesthetic techniques.What's NewWe know that neuraxial ultrasound is a useful complement to clinical examination when performing lumbar central neuraxial blocks. It provides anatomical information including the depth of the epidural space, the identity of a given intervertebral level, and the location of the midline and interspinous/interlaminar spaces. This information can be used to successfully guide subsequent needle insertion.Since 2010, new data from RCTs and 1 meta-analysis suggest that neuraxial ultrasound increases the success and reduces the technical difficulty of lumbar central neuraxial blocks. Findings from the meta-analysis suggest that neuraxial ultrasound reduces the risk of traumatic procedures, and thus may possibly contribute to the safety of lumbar central neuraxial blocks.

Anesthetic techniques can significantly influence postoperative outcomes by modulating inflammatory cytokine release and oxidative stress (OS). This study aimed to compare serum levels of OS biomarkers and inflammatory cytokines in patients undergoing abdominal hysterectomy under spinal anesthesia (SA) or general anesthesia (GA). A single-blinded, non-randomized controlled trial was conducted on forty-two patients (American Society of Anesthesiologists (ASA) class I and II) undergoing abdominal hysterectomy. Two groups of patients were assigned: SA and GA. To measure the levels of inflammatory cytokines (tumor necrosis factor-alpha [TNF-α], interleukin-1 beta [IL-1β], and interleukin-6 [IL-6]), as well as anti-inflammatory cytokine (interleukin-10 [IL-10]) and oxidative stress (OS) biomarkers (superoxide dismutase [SOD], catalase [CAT], and malondialdehyde [MDA]), blood samples were collected both before anesthesia and 48 h after surgery. Postoperatively, the serum levels of MDA significantly increased, while enzyme activity of CAT decreased in the GA group compared to pre-anesthesia levels. The MDA concentration was significantly higher in the GA group compared to the SA group. Besides, the SOD activity was significantly lower in the GA group than in the SA group. TNF-α and IL-6 serum levels were raised in the GA group postoperatively compared to pre-anesthesia levels. Furthermore, the concentration of TNF-α and IL-6 was significantly higher in the GA group than in the SA group. There was a notable difference in the ratio of IL-6/IL-10 between the two groups. GA significantly increased inflammatory factor levels and decreased serum antioxidants after abdominal hysterectomy compared to SA. These results indicate a lower inflammatory response to SA than GA.

Interventional spine and pain procedures cover a far broader spectrum than those for regional anesthesia, reflecting diverse targets and goals. When surveyed, interventional pain and spine physicians attending the American Society of Regional Anesthesia and Pain Medicine (ASRA) 11th Annual Pain Medicine Meeting exhorted that existing ASRA guidelines for regional anesthesia in patients on antiplatelet and anticoagulant medications were insufficient for their needs. Those surveyed agreed that procedure-specific and patient-specific factors necessitated separate guidelines for pain and spine procedures.In response, ASRA formed a guidelines committee. After preliminary review of published complication reports and studies, committee members stratified interventional spine and pain procedures according to potential bleeding risk as low-, intermediate-, and high-risk procedures. The ASRA guidelines were deemed largely appropriate for the low- and intermediate-risk categories, but it was agreed that the high-risk targets required an intensive look at issues specific to patient safety and optimal outcomes in pain medicine.The latest evidence was sought through extensive database search strategies and the recommendations were evidence-based when available and pharmacology-driven otherwise. We could not provide strength and grading of these recommendations as there are not enough well-designed large studies concerning interventional pain procedures to support such grading. Although the guidelines could not always be based on randomized studies or on large numbers of patients from pooled databases, it is hoped that they will provide sound recommendations and the evidentiary basis for such recommendations.

Reports have suggested the use of intravenous infusion of vasopressors as an approach to prevent spinal anesthesia-induced hypotension (SAIH) in women undergoing cesarean deliveries. However, data on the suitability of this technique for obese people are limited. As such, the current experiment was designed to clarify the dose-response relationship associated with the preventive administration of phenylephrine to avoid SAIH during cesarean delivery in obese parturients under combined spinal-epidural anesthesia. The current study included 100 parturients with a body mass index ≥30 kg/m who were undergoing cesarean section delivery. They were randomly treated with phenylephrine at different doses: 0.375, 0.5, 0.625, or 0.75 μg/kg/min. An infusion of phenylephrine was deemed beneficial if hypotension was absent, with hypotension defined as a systolic blood pressure <90 mmHg or <80% of the baseline value between spinal injection and the delivery of the newborn. The 50% and 90% effective doses (ED and ED , respectively) for prophylactic phenylephrine were determined via a probit regression. Respective rates of hypotension in the 0.375, 0.5, 0.625, and 0.75 groups were 52% (13/25), 40% (10/25), 20% (5/25), and 0% (0/25). ED and ED values of 0.42 (95% confidence interval 0.30-0.48) and 0.68 (95% confidence interval 0.60-0.87) μg/kg/min were calculated for phenylephrine treatment. The study results indicated that prophylactic phenylephrine, which prevents SAIH in obese parturients following cesarean delivery, has calculated values of 0.42 and 0.68 μg/kg/min. These findings may contribute to developing appropriate clinical practice guidelines for improved patient management. https://www.chictr.org.cn/bin/project/edit?pid=153050 . Identifier ChiCTR2200058125.

Lumbar puncture is a minimally invasive procedure that utilizes a spinal needle to puncture the lumbar epidural space to take a sample from the cerebrospinal fluid or inject drugs for diagnostic and therapeutic purposes. Physicians rely on their expertise to localize epidural space. Due to its critical procedure, the failure rate can reach up to 28%. Hence, a high level of experience and caution is required to correctly insert the needle without puncturing the dura mater, which is a fibrous layer protecting the spinal cord. Failure of spinal anesthesia is, in some cases, related to faulty needle placement techniques since it is blindly inserted. Therefore, advanced techniques for localization of the epidural space are essential to avoid any possible side effects. As for epidural space localization, various ideas were carried out over recent years to provide accurate identification of the epidural space. Subsequently, several methodologies based on mechanical and optical schemes have been proposed. Several research groups worked from different aspects of the problem, namely, the clinical and engineering sides. Hence, the main goal of this paper is to review this research with the aim of remedying the gap between the clinical side of the problem and the engineering side by examining the main techniques in building sensors for such purposes. This manuscript provides an understanding of the clinical needs of spinal needles from an anatomical point of view. Most importantly, it discusses the mechanical and optical approaches in designing and building sensors to guide spinal needles. Finally, the standards that must be followed in building smart spinal needles for approval procedures are also presented, along with some insight into future directions.

Background: Epidural injections have been used since 1901 in managing low back pain and sciatica. Spinal pain, disability, health, and economic impact continue to increase, despite numerous modalities of interventions available in managing chronic spinal pain. Thus far, systematic reviews performed to assess the efficacy of epidural injections in managing chronic spinal pain have yielded conflicting results. Objective: To evaluate and update the clinical utility of the efficacy of epidural injections in managing chronic spinal pain. Study Design: A systematic review of randomized controlled trials of epidural injections in managing chronic spinal pain. Methods: In this systematic review, randomized trials with a placebo control or an active-control design were included. The outcome measures were pain relief and functional status improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Best evidence synthesis was conducted based on the qualitative level of evidence (Level I to V). Data sources included relevant literature identified through searches of PubMed for a period starting in 1966 through August 2015; Cochrane reviews; and manual searches of the bibliographies of known primary and review articles. Results: A total of 52 trials met inclusion criteria. Meta-analysis was not feasible. The evidence in managing lumbar disc herniation or radiculitis is Level II for long-term improvement either with caudal, interlaminar, or transforaminal epidural injections with no significant difference among the approaches. The evidence is Level II for long-term management of cervical disc herniation with interlaminar epidural injections. The evidence is Level II to III in managing thoracic disc herniation with an interlaminar approach. The evidence is Level II for caudal and lumbar interlaminar epidural injections with Level III evidence for lumbar transforaminal epidural injections for lumbar spinal stenosis. The evidence is Level II for cervical spinal stenosis management with an interlaminar approach The evidence is Level II for axial or discogenic pain without facet arthropathy or disc herniation treated with caudal or lumbar interlaminar injections in the lumbar region; whereas it is Level II in the cervical region treated with cervical interlaminar epidural injections. The evidence for post lumbar surgery syndrome is Level II with caudal epidural injections and for post cervical surgery syndrome it is Level II with cervical interlaminar epidural injections. Limitations: Even though this is a large systematic review with inclusion of a large number of randomized controlled trials, the paucity of high quality randomized trials literature continues to confound the evidence. Conclusion: This systematic review, with an assessment of the quality of manuscripts and outcome parameters, shows the efficacy of epidural injections in managing a multitude of chronic spinal conditions. Key words: Chronic pain, spinal pain, epidural injections, local anesthetic, steroids, interlaminar epidural injections, caudal epidural injections, transforaminal epidural injections

Background Awake surgery, under spinal anesthesia (SA), is an alternative to surgery under general anesthesia (GA), in neurological and spine surgery. In the literature, there seem to be some evidence supporting benefits associated with the use of this anesthetic modality, as compared to GA. Currently, there is a notable lack of updated and comprehensive review addressing the complications associated with both awake SA and GA in spine surgery. We hence aimed to perform a systematic review of the literature and meta-analysis on the topic. Methods A systematic search was conducted to identify studies that assessed SA in spine surgery from database inception to April 14, 2023, in PubMed, Medline, Embase, and Cochrane databases. Outcomes of interest included estimated blood loss, length of hospital stay, operative time, and overall complications. Meta-analysis was conducted using random effects models. Results In total, 38 studies that assessed 7820 patients were included. The majority of the operations that were treated with SA were single-level lumbar cases. Awake patients had significantly shorter lengths of hospital stay (Mean difference (MD): − 0.40 days; 95% CI − 0.64 to − 0.17) and operative time (MD: − 19.17 min; 95% CI − 29.68 to − 8.65) compared to patients under GA. The overall complication rate was significantly higher in patients under GA than SA (RR, 0.59 [95% CI 0.47–0.74]). Patients under GA had significantly higher rates of postoperative nausea/vomiting RR, 0.60 [95% CI 0.39–0.90]) and urinary retention (RR, 0.61 [95% CI 0.37–0.99]). Conclusions Patients undergoing awake spine surgery under SA had significantly shorter operations and hospital stays, and fewer rates of postoperative nausea and urinary retention as compared to GA. In summary, awake spine surgery offers a valid alternative to GA and added benefits in terms of postsurgical complications, while being associated with relatively low morbidity.

Shivering affects 52 % of patients undergoing caesarean delivery under neuraxial anaesthesia. Despite extensive research focused on its prevention, there is still no consensus regarding optimal pharmacological treatment. This systematic review and network meta-analysis aims to compare available intravenous treatments of perioperative shivering in patients undergoing caesarean delivery under neuraxial anaesthesia. We searched seven databases (PubMed MEDLINE, Scopus, Web of Science, Embase, LILACS, Cochrane CRCT and clinicaltrials.gov) for randomised controlled trials comparing intravenous treatments of perioperative shivering during caesarean delivery and performed a Bayesian model network meta-analysis. We assessed study quality using the Cochrane risk of bias assessment tool. The primary outcome evaluated in this meta-analysis was shivering control (cessation or significant reduction in intensity), and secondary outcomes included time to shivering control, shivering recurrence, and incidence of maternal nausea. Twenty randomised controlled trials, with a total of 1983 patients, were included in this analysis. Network estimates of odds ratios (OR [95 % Credible Interval]) of effective treatment of shivering compared with saline were: dexmedetomidine (38.1 [14.2 to 111.5]), tramadol (33.6 [15.1 to 81.8]), nalbuphine (26.2 [10.8 to 80.2]), meperidine (20.9 [6.2 to 73.1]), ondansetron (6.6 [2.2 to 23.2]), and clonidine (3.2 [0.6 to 14.9]). The rank order of interventions by surface area under the cumulative ranking curve scores (in parenthesis) for shivering control was dexmedetomidine (0.87) > tramadol (0.85) > nalbuphine (0.74) > meperidine (0.66) > ondansetron (0.41) > clonidine (0.3) > amitriptyline (0.03). Dexmedetomidine was also the top-ranked intervention for time to shivering control, shivering recurrence and maternal nausea. We judged the certainty in the evidence to be moderate for dexmedetomidine and nalbuphine, and low for all other interventions. This network meta-analysis identified four effective intravenous treatments for shivering in patients undergoing caesarean delivery under neuraxial anaesthesia: dexmedetomidine, tramadol, nalbuphine and meperidine. Dexmedetomidine was the top-ranked intervention for all outcomes. •Comparison of intravenous agents for shivering control during caesarean section under neuraxial anaesthesia.•Dexmedetomidine, tramadol, nalbuphine and meperidine effectively control perioperative shivering.•Top-ranked treatments show minor differences in absolute effectiveness, suggesting that selection should be based on factors like clinical context, safety, cost, and availability.•Dexmedetomidine ranks highest for effective shivering control, fastest onset of action, lowest recurrence rate, and lowest incidence of maternal nausea.•Tramadol, meperidine and nalbuphine are associated with maternal nausea.

During cesarean section, hypotension is a frequent side effect of spinal anesthesia. As a sitting or lateral position is required for spinal anesthesia performance, which of these two positions is more likely to cause intraoperative nausea, vomiting, and hypotension is still unknown. This meta-analysis compared the effects of these two positions on maternal hemodynamics and intraoperative nausea and vomiting. Systematic review and meta-analysis. Operating room. This study included 803 patients from 12 randomized controlled trials (RCTs). Neuraxial anesthesia in sitting position vs. lateral position. We chose RCTs comparing the effects of spinal anesthesia in the sitting and lateral positions on maternal hemodynamics by thoroughly searching PubMed, Embase, the Cochrane Library, and the Web of Science for articles published from database inception until October 31, 2022. The Cochrane Handbook was used to assess the methodological quality of each RCT; the results were analyzed using RevMan 5.4 software; and the Egger test was used to assess publication bias. 12 randomised controlled trials with 803 participants were ultimately included in the final analysis. No significant differences were observed between the two positions in terms of the incidence of hypotension(RR, 0.82; 95% CI, 0.58-1.16; P = 0.26; I2 = 66%), lowest systolic blood pressure(MD, -0.81; 95% CI, -7.38-5.75; P = 0.81; I2 = 86%), the dose of ephedrine(MD, -1.19; 95% CI, -4.91-2.52; P = 0.53; I2 = 83%), and number of parturients requiring ephedrine(RR, 0.97; 95% CI, 0.64-1.46; P = 0.88; I2 = 74%). For the incidence of intraoperative nausea and vomiting, there was no statistical difference between the two positions. Parturients undergoing elective cesarean section under spinal anesthesia in the sitting or lateral position experienced similar incidence of hypotension, and there were no significant differences between these two positions in terms of the amount of ephedrine administered or the number of patients needing ephedrine. In both positions, the frequency of nausea and vomiting was comparable. The ideal position for anesthesia can be chosen based on the preferences and individual circumstances of the parturient and anesthesiologist.