To the Editor We read with interest the case report of Choi et al, describing the use of the transforaminal approach to administer an epidural blood patch in a patient with multilevel spinal fusion. We commend the authors for successfully relieving the symptoms of postdural puncture headache in this challenging scenario, but we suggest that another treatment option might have also been considered, namely, a sphenopalatine ganglion block. The sphenopalatine ganglion block is a simple and minimally invasive technique described more than a century ago, but familiar to relatively few anesthesiologists. The sphenopalatine ganglion is readily accessible by topical intranasal administration of medication, as it located proximate to the posterior aspect of the middle turbinate bilaterally, and separated from the nasal cavity by mucosa and a thin layer of connective tissue. It is a parasympathetic ganglion with neuronal projections to cerebral and dural blood vessels, and its activation produces vasodilation, plasma protein extravasation and neurogenic inflammation. This is thought to result in activation of nociceptors and to contribute to the sensation of headache. Reversal of these effects may be achieved by inhibiting parasympathetic outflow from the ganglion. Sphenopalatine ganglion block can be achieved by administering local anesthetics, for example, lidocaine 4% or bupivacaine 0.5%, into both nares via soaked cottontipped applicators or by simply dripping local anesthetics into the nose with the neck extended . A 17year chart review comparing epidural blood patch with sphenopalatine ganglion block for postdural puncture headache found that sphenopalatine ganglion block resulted in more rapid onset of headache relief, no further complications, and fewer emergency room visits post discharge than epidural blood patch. Although epidural blood patch is the ‘gold standard’ for treating postdural puncture headache, it is not innocuous and devastating complications have been reported. Conversely, the adverse effects of the sphenopalatine ganglion block are minor and transient: nostril discomfort, bitter taste and oropharyngeal numbness, which all resolve within 20 min. Furthermore, patients with prior spinal surgery and attendant scar tissue and adhesions may have a greater likelihood of another dural puncture during the epidural blood patch procedure. The sphenopalatine ganglion block has the distinct advantage of avoiding instrumentation of the neuraxis, a particularly important consideration in the case described. Our practice in postdural puncture patients with challenging neuraxial anatomy is to attempt treatment first using the sphenopalatine ganglion block and reserving more invasive and complex approaches such as the one described in the case report only if the sphenopalatine ganglion block fails.

BACKGROUND: Early reports associating severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection with adverse pregnancy outcomes were biased by including only women with severe disease without controls. The Society for Obstetric Anesthesia and Perinatology (SOAP) coronavirus disease 2019 (COVID-19) registry was created to compare peripartum outcomes and anesthetic utilization in women with and without SARS-CoV-2 infection delivering at institutions with widespread testing. METHODS: Deliveries from 14 US medical centers, from March 19 to May 31, 2020, were included. Peripartum infection was defined as a positive SARS-CoV-2 polymerase chain reaction test within 14 days of delivery. Consecutive SARS-CoV-2–infected patients with randomly selected control patients were sampled (1:2 ratio) with controls delivering during the same day without a positive test. Outcomes were obstetric (eg, delivery mode, hypertensive disorders of pregnancy, and delivery <37 weeks), an adverse neonatal outcome composite measure (primary), and anesthetic utilization (eg, neuraxial labor analgesia and anesthesia). Outcomes were analyzed using generalized estimating equations to account for clustering within centers. Sensitivity analyses compared symptomatic and asymptomatic patients to controls. RESULTS: One thousand four hundred fifty four peripartum women were included: 490 with SARS-CoV-2 infection (176 [35.9%] symptomatic) and 964 were controls. SARS-CoV-2 patients were slightly younger, more likely nonnulliparous, nonwhite, and Hispanic than controls. They were more likely to have diabetes, obesity, or cardiac disease and less likely to have autoimmune disease. After adjustment for confounders, individuals experiencing SARS-CoV-2 infection exhibited an increased risk for delivery <37 weeks of gestation compared to controls, 73 (14.8%) vs 98 (10.2%) (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.03–2.09). Effect estimates for other obstetric outcomes and the neonatal composite outcome measure were not meaningfully different between SARS-CoV-2 patients versus controls. In sensitivity analyses, compared to controls, symptomatic SARS-CoV-2 patients exhibited increases in cesarean delivery (aOR, 1.57; 95% CI, 1.09–2.27), postpartum length of stay (aOR, 1.89; 95% CI, 1.18–2.60), and delivery <37 weeks of gestation (aOR, 2.08; 95% CI, 1.29–3.36). These adverse outcomes were not found in asymptomatic women versus controls. SARS-CoV-2 patients (asymptomatic and symptomatic) were less likely to receive neuraxial labor analgesia (aOR, 0.52; 95% CI, 0.35–0.75) and more likely to receive general anesthesia for cesarean delivery (aOR, 3.69; 95% CI, 1.40–9.74) due to maternal respiratory failure. CONCLUSIONS: In this large, multicenter US cohort study of women with and without peripartum SARS-CoV-2 infection, differences in obstetric and neonatal outcomes seem to be mostly driven by symptomatic patients. Lower utilization of neuraxial analgesia in laboring patients with asymptomatic or symptomatic infection compared to patients without infection requires further investigation.

The primary failure rate of labor and surgical analgesia may be as high as 17%. The misidentification of the epidural space with conventional loss of resistance techniques is likely a major contributor.[1][1] Specificity is increased by identifying electronically transduced variation in epidural

quadratus lumborum blocks in the setting of laparoscopic nephrectomy and hysterectomy as well as Cesarean delivery. More importantly, the dose of local anesthetic results from the mathematical product of volume and concentration. Thus, one could simply compensate for a higher volume by using a lower concentration. For example, 62.5 mL of adrenalized bupivacaine 0.25% amounts to 156 mg of bupivacaine, an infratoxic dose (<3 mg/ kg) for patients weighing 52 kg or more. Alternately, if one were to use bupivacaine 0.2%, the 62.5 mL volume becomes a nonissue for subjects weighing 41 kg or more. Bendtsen et al conclude their commentary by reiterating their belief that obturator blockade with suprainguinal fascia iliaca blocks lacks “sound anatomic basis”. Although our results combined with Bravo et al’s findings suggest the contrary, we respect all freedom of belief. Since we are not missionaries, we respectfully refrain from belittling native myths and beliefs. Our humble goal is the sharing of science. Ultimately, using actual data, the Journal’s readers will be able to decide for themselves.

Shoulder tip pain may occur after thoracic surgical procedures. The pain is caused by diaphragmatic irritation and is referred to the shoulder. Shoulder tip pain is often resistant to treatment with conventional analgesics. The sphenopalatine ganglion block has been described to manage many painful conditions. We report here the first use of this block to treat shoulder tip pain in 2 thoracic surgical patients. In both patients, the block produced rapid and sustained relief of the shoulder tip pain. We suggest that sphenopalatine ganglion block be considered to treat postoperative shoulder tip pain after thoracic surgical procedures.

Study objective: At our hospital, although >90% of nulliparous parturients eventually choose epidural analgesia for labor, many delay its initiation, experiencing considerable pain in the interim. This survey probed parturients' views about the timing of initiation of epidural labor analgesia.Design: Single-center, nonrandomized quantitative survey.Setting: Labor and delivery suite in a large tertiary academic medical center.Patients: Two hundred laboring nulliparous women admitted to the labor and delivery suite. Interventions: After their pain was relieved, parturients completed a questionnaire regarding their decision to request labor epidural analgesia.Measurements: A variety of factors regarding epidural use were assessed including the influence of painful contractions and of childbirth education class attendance on the decision to request epidural analgesia, and parturients' perception of the timing of epidural initiation on the progress and outcome of labor.Main results: Analysis revealed that the desire of parturients to use epidural analgesia was increased from 27.9% before the onset of painful contractions to 48.2% after (p < 0.01). Two-thirds of participants attended a non-physician taught childbirth education class. An antepartum plan to definitely forgo an epidural was 1.8 times more likely among women who attended a childbirth class when compared to those who did not attend. (OR = 1.8; 95%Cl:1.1-3.1; p = 0.04). The most common views affecting decision-making were that epidural analgesia should not be administered "too early" (67.5%), and that it would slow labor (68.5%). Both of these views were more likely to be held if the parturient had attended a childbirth class, OR = 2.0 (95%CI:1.1-3.8; p = 0.03) and OR = 2.0 (95% CI: 1.1 to 3.7; p = 0.03), respectively.Conclusions: We found that nulliparous parturients have misconceptions about epidurals, which are not supported by evidence-based medicine. Moreover, we found that attendance at childbirth education classes was associated with believing these misconceptions. (C) 2017 Published by Elsevier Inc.

There is a chronic shortage of anesthesiologists in Israel. The study by Cohen et al. suggests that a marketing campaign may be one method of addressing this shortage. This commentary argues for a more comprehensive strategy based on the US experience. This would not only involve marketing as suggested by Cohen et al. but would also involve a fundamental change in the Israel anesthesia care model, as well as providing substantial financial incentives to young physicians. We believe that a combination of these approaches will help to alleviate the shortage of anesthesia providers in Israel. Creating a new class of physician extenders, namely, anesthesiologist assistants, would also provide an employment pathway for the skilled medical technicians trained by the Israel Defense Forces, and other non-physicians with an interest in anesthesiology.

Introduction/Background Prior to beginning their obstetric anesthesia rotation, most residents receive only minimal training in the placement of epidural catheters. Insertion of an epidural catheter under strict sterile technique requires careful attention to detail throughout a multi-step process. Guidance and instruction is required throughout this process to properly train residents. A practical problem in the labor and delivery suite is that the training must be done in the presence of awake and alert patients in varying degrees of pain. Furthermore, the patient’s significant other is typically present during the epidural procedure. These conditions make for a suboptimal teaching environment for the novice operator. In order to provide trainees with a safe and standardized controlled environment for learning, we created a pre-rotation educational program that combines video instruction with epidural simulation and real-time feedback to better prepare our residents for epidural insertion. Methods We produced a narrated video utilizing an actress and an epidural simulator, in which all the steps required in placing an epidural catheter under sterile technique are depicted, from sterile prep and drape of the field to securing the epidural catheter port to the patient’s shoulder. Residents are scheduled to participate in the simulation prior to beginning their obstetric anesthesia rotation. They are provided with a weblink to the training video for online viewing prior to attending the simulation session. The session is mentored by an obstetric anesthesiologist and the residents are provided with real-time feedback. Emphasis is placed upon maintaining strict sterile technique, professionalism and compassion while interacting with the simulated patient. After the learners perform the entire sequence, they are given the opportunity to repeat it independently to further enhance their learning. Results: Conclusion Resident evaluation of this educational program initiative has been uniformly positive. Learners consistently cite the advantage of having familiarity with the technical skills and the equipment involved in inserting epidural catheters prior to performing the procedure on live patients. In addition, participants have remarked that the simulation decreased their anxiety about beginning their obstetric anesthesia rotation. Residents also value their contact with the attending staff and the opportunity they have to understand the requirements of the rotation before being faced with a new and unfamiliar environment. Attending anesthesiologists have expressed satisfaction that the residents have been exposed to some of the basic procedures that must be mastered dring their rotation.

There is a compelling need for an ultralong-acting local anesthetic. Previously, we demonstrated in mice and humans that encapsulation of bupivacaine into large multivesicular liposomes (Bupisome) prolongs drug residence time and analgesic duration at the injection site while reducing peak plasma concentration. However, we observed considerable leakage of bupivacaine from the liposomes during storage at 4°C. This deficiency was overcome by modifying the lipid composition of Bupisome and by entrapping them in a Ca-alginate cross-linked hydrogel (Bupigel), forming stable, soft, injectable (3–5mm) beads. Bupisome are not released from Bupigel, but their encapsulated bupivacaine is released into the bulk solution. Adding 0.5% to 2.0% free bupivacaine to the Bupigel prevented net loss of bupivacaine from the Bupisome after storage at 4°C for 2years, and at 37°C enough bupivacaine was released to prolong analgesia. For injection subcutaneously into mice, the beads are drawn into a syringe, leaving the small amount of free bupivacaine behind. Both Bupisome and Bupigel formulations significantly prolonged analgesia in mice compared to standard bupivacaine, with Bupigel performing better than Bupisome.

Regional pain relief may be too risky in patients with coagulation disorders, whether they're induced by anticoagulants to manage or prevent adverse pregnancy outcomes linked with VTE or thrombophilia, or due to a coagulopathy. Benefits and risks can include a rare but catastrophic complication: spinal hematoma.

We read with interest the debate about patient-controlled epidural analgesia (PCEA) for labor and would like to comment regarding some historical allusions in Dr. Aveling’s remarks. [1] Aveling W. Opposer: Patient-controlled epidural analgesia is the technique of choice for epidural analgesia in labor. Int J Obstet Anesth. 2005; 14: 328-331 Abstract Full Text Full Text PDF PubMed Google Scholar Ignac Semmelweis did indeed espouse hand washing with chlorinated lime solution to prevent the transmission of puerperal sepsis in 1847, but his cause of death had nothing to do with a wound he received during an autopsy. Rather, the physician who succumbed after accidentally cutting himself during an autopsy on a woman who had died of puerperal sepsis in 1847 was Dr. Jakob Kolletschka, a forensic pathologist and a close friend of Semmelweis. When an autopsy was performed on Dr. Kolletschka, the findings were indistinguishable from those in women dying of puerperal sepsis, providing Semmelwies with an important clue to the mode of transmission of the disease. [2] Nuland S.B. The doctors’ plague: germs, childbed fever, and the strange story of Ignac Semmelweis. W.W. Norton, New York2003 Google Scholar

The first anesthetic for childbirth and the first recognition of the importance of hand hygiene in obstetrics coincidentally occurred within 5 months of one another in 1847. More than 150 years later, one would have thought that these milestone events would have been fully integrated into practice. However, individuals resist transformational change, which is defined as a fundamental alteration in their beliefs, attitude, and behavior, even when they are confronted with incontrovertible facts. This resistance to change may explain why, in 2005, a large percentage of health care providers still do not practice acceptable hand hygiene, and the pain of childbirth continues to be extolled by some as a necessary part of womanhood, just as pharmacologic pain relief is discouraged.

Purpose. To evaluate the dehydration-rehydration technique to prepare a formulation of liposomal bupivacaine, and to assess its analgesic efficacy.