Local and regional anaesthesia

Materials and Methods: A review of the notes provided by the anaesthetist

was undertaken in the post-operative period for forty-four patients who had
received CSE, epidural or spinal anaesthetic techniques.
Results: In thirty cases (68.2%) some documented evidence of a discussion of the elements of the regional technique and its associated risks and
benefits was seen. The following discussions of risks were documented:
headache 17 (39%), paraesthesia 0, nerve damage 15 (34%), failure 12 (27%),
shivering 1 (2%), infection 2 (5%), haematoma 1 (2%), hypotension 4 (9%),
urinary retention 5 (11%), nausea 4 (9%) and reason for lack of discussion 0.
Conclusion(s): In nearly a third of cases anaesthetists failed to document
the discussion of risks. The particular risks discussed varied considerably.
The anaesthetist will always be required to exercise clinical judgement in
discussion of risks but the authors feel that reasons for not discussing risks
(which can be perfectly valid) should also be documented. Documentation
should be improved to avoid legal complications. This might be achieved by
improving training of anaesthetists on issues of consent. Evidence of understanding consent might constitute part of the forthcoming re-validation
process.
Reference:
1. Royal College of Anaesthetists Raising the Standard 2000 Dr E James Consent to
anaesthesia 1.2.

8AP1-6
Confirmation of epidural puncture by change in epidural
pressure using Queckenstedt-test procedure in patients with
cervical spinal canal stenosis
R. Yokoyama, T. Yokoyama, T. Ushida, A. Imoto, K.A. Sluka
Department of Anesthesiology and Critical Care Medicine, Kochi Medical
School, Nankoku, Japan
Background and Goal of study: The loss-of-resistance test is the most
popular method for identifying the epidural space, but it cannot confirm
epidural puncture. Therefore, we developed a new method to confirm epidural
puncture by assessing indirect changes in epidural pressure (EP) using the
Queckenstedt-test1 procedure (E-QST)2, which increases subarachnoid
pressure by compressing the internal jugular veins. This method depends on
the dynamics of cerebrospinal fluid (CSF), hence blockade of CSF flow,
occuring with severe spinal stenosis, is predicted to reduce changes in EP
using E-QST. Thus, we examined the effect of spinal stenosis on the E-QST.
Material and Methods: After institutional approval and informed consent,
patients undergoing cervical spine surgery were enrolled for this study.
Epidural puncture using the loss-of-resistance test was utilized to insert an
electrode after anesthetic induction. EP was monitored with E-QST through
a Tuohy needle to confirm epidural puncture. The insertion of the electrode
into the epidural space was confirmed by observation of muscle twitch
evoked after electric stimulation using the electrode.
Results and Discussion: In 60 patients, epidural puncture was performed
with the loss-of-resistance test; a second trial was required for 13 patients
due to less catheter advance. Increased EP during E-QST was observed in
57/73 trials. When increased EP was observed, epidural puncture was always
successful. The sensitivity and specificity of this E-QST method was 91.9%
(57/62) and 100% (11/11). The positive and negative predictive values were
100% (57/57) and 68.8% (11/16) respectively.
Conclusion: EP monitoring combined with E-QST offers a reliable method
for confirming epidural puncture in combination with the loss-of-resistance
test, even if patients have spinal canal stenosis.
References:
1
2

Queckenstedt H. Deuche Zeitshaft fur Nervenheilkunde 1916; 55: 32533.

Yokoyama T, et al. J Clin Anesth (Japan) 2005; 29: 18158.

8AP1-7
The effect of ketamine on combination of bupivacaine and
fentanyl for quality of epidural block

87

bupivacaine and 100cg fentanyl, Group BFK received 30 mg additional

ketamine to this combination of same dose bupivacaine and fentanyl. Onset
time of sensory and motor blockage, maximum level of sensory block, degree
of motor block, regression of two segments, duration of sensory and motor
blockade were evaluated. Statistical analyses were performed by Kruskall
Wallis and Chi Square tests.
Results and Discussions: Demographical and haemodynamic parameters,
onset of sensory and motor blockade, and the degree of motor block were
similar. Maximum level of sensory block was higher in Group BFK. Regression
time of two segments and duration of sensory block were lower in Group BFK.
Table

Onset of sensory block (minute)

Two segment regression time (minute)
Duration of sensorial block (minute)
Maximum level of sensory block

BF

BFK

2,9  1
197,7  28
252,5  25
T6(T4T6)

2,3  0,5
121  42
213,5  23
T2(T2T4)

0,068
 0,001
 0,001
 0,001

Conclusions: Preoperative use of epidural ketamine antagonizes the beneficial effects of epidural fentanyl.
Reference:
1

Hoffmann VLH, et al. European Journal of Pain 2003; 7: 121130.

8AP1-8
Epidural analgesia decreases intraabdominal pressure in
postoperative patients with intraabdominal hypertension
A. Varosyan, G. Mkhoyan, G. Harutyunyan, R. Hakobyan
Anaesthesiology and Intensive Care, Yerevan State Medical University,
Yerevan, Armenia
Background and Goal of Study: Intraabdominal hypertension (IAH) causes
significant morbidity and mortality in critically ill surgical patients. Pain relief
may hypothetically decrease the secondary muscle spasm and increase the
anterolateral abdominal wall compliance, therefore decreasing intraabdominal pressure (IAP). To rule out this hypothesis the effect of epidural analgesia
on IAP in postoperative patients with IAH was investigated.
Materials and Methods: In a prospective double-blinded study 58 postoperative critically ill surgical patients with IAH receiving postoperative epidural
analgesia were investigated. IAH defined as a sustained IAP
12 mmHg or
an abdominal perfusion pressure (APP)  60 mmHg recorded by a minimum
of 3 standardized measurements conducted 6 hours apart. Epidural catheterization was performed at Th8 Th10 level. After test dose and correct placement of the catheter patients received 10 ml of 0,2% ropivacaine, followed
by its continuous infusion at a rate of 5 ml/h for maximum 96 hours. IAP was
measured transvesically after instillation of 50 ml saline in supine position
immediately before and 1 hour after initiation of epidural analgesia and every
6 hours consequently. Mean arterial pressure (MAP) was measured invasively in all patients. APP was calculated for each IAP measurement as
APP  MAPIAP. A repeated measure ANOVA was used to analyze
repeated measurements of IAP, MAP and APP.
Results and Discussions: ANOVA for repeated measures showed significant
within subject decrease in IAP (p  0.0001), but failed to show any significant
differences for repeated measurements of MAP (p  0.147). Mean and standard
deviation values of IAP, APP and MAP in all observations immediately before
and 1 hour after initiation of epidural analgesia were 13.909  3.006 mmHg vs.
7.727  3.439 mmHg (p  0.0001); 63.732  16.244 mmHg vs. 75.658 
18.986 mmHg (p  0.005) and 77.641  17.398 mmHg vs. 83.385 
17.781 mmHg (p  0.071) respectively. Measurements show a significant
decrease of IAP with no significant change in MAP, which maintained APP
stable or even elevated during epidural analgesia: APP 1 hour  1 day
(p  0.001), 1 day  2 day (p  0.006).
Conclusion: Continuous thoracic epidural analgesia significantly decreases
IAP and improves APP with no hemodynamic compromise in critically ill
postoperative patients with IAH.

L. Ozdogan, M. Erol, V. Taspinar, S. Barcin, F. Sahin

Anaesthesiology and Reanimation, Numune education and research
hospital, Ankara, Turkey
Background and Goal of Study: Opioid and local anesthetic combination
has been used to enhance the quality of epidural anesthesia. It has reported
that epidural ketamine tends to antagonize the antinociceptive activity of
fentanyl in rat(1).The aim of this study was to evaluate the effect of ketamine
on combination of bupivacaine and fentanyl for quality of epidural block.
Materials and Methods: After ethic committee approval and informed consent, forty patients undergoing hip arthroplasty were studied. Epidural catheter
was inserted L34 or L45 interspaces by lost of resistance with air in sitting
position. Patients randomly divided to two groups. Group BF received 75 mg

8AP1-9
Selective segmental epidural anesthesia for ambulatory
pilonidal sinus surgery
Y. Pala, S. Okur, V. Taspinar, F. Donmez, S. Barcn
II. Anesthesiology and Reanimation, Ankara Numune Education and
Research Hospital, Ankara, Turkey
Background and Goal of Study: Epidural anesthesia (EA) can provide
sensorial block with no motor blockade and the level of block can be easily
controlled (1). Our aim was to compare low dose segmental EA with conventional EA for ambulatory pilonidal sinus (PS) surgery.