A continuous leakage in association with hypovolemia and hypotention of the cerebrospinal fluid is the primary cause of a post-spinal headache. The spinal blood patch is known to be the best choice of treatment for a severe postspinal headache, and measurements of cerebrospinal fluid pressure with saline injection into the lumbar spinal space have been reported. However, a dynamic correlation of the pressure change between epidural and CSF pressure after the epidural injection of the volume has not been known. This study was primarily carried out to investigate dynamic changes and the correlation between epidural and CSF pressure with and without epidural volume injection so that it would be helpful to understand the mechanism as to the immediate and permanent cure, and recurrence of post-spinal headache. Twenty cases were divided into two groups: Group I (control): Normal CSF and epidural pressure were measurd in a sitting position (10 cases) and in a lateral position (10 cases). Group II: CSF and epidural pressure after the injection of 2% lidocaine 10 ml were measured in a sitting position (10 cases) and in a lateral position (10 cases). The differences between CSF and epidural pressure from groups I and II were calculated. The rusults were as follows. CSF pressure: The mean Mean opening pressure was 37.3+/-4.2 cm H2O, mean pressure after injeciton was 41.3+/-6.1 cm H2O and pressure rise was 4 cm H2O (10.7%) in the sitting position, and the mean opening pressure was 9.3+/-3.8 cm H2O mean pressure after injection was 13.9+/-5.2 cm H2O and pressure rise was 4.6 cm H2O (49.5%) in the lateral position. Epidural pressure: The mean initial pressure was 5.82.6 cm H2O, mean pressure after injection was 16.9+/-12.4 cm H2O and pressure rise was 22.7 cm H2O (391.3%) in the sitting posittion, and mean initial pressure was 6.1+4.0 cm H2O, mean pressure after injection was 9.5+ 7.9 cm H2O, and pressure rise was 15.6 cm H2O (255.7%) in the lateral position. Difference between CSF and epidural pressure (CSF pressure-epidural pressure, cm H2O): The mean pressure difference in the control group was 43.1+5.7 cm H2O and mean pressure difference after injection was 24,4+/-12.4 cm H2O in sitting position, and mean pressure difference in the control group was 15.4+/-4.1 cm H2O and mean pressure difference after injection was 4.4+/-10.1 cm H2O in lateral position. It is obvious that the injection of 10 ml of 2% lidocaine reduced the pressure difference greatly between the subarachnoid and epidural spaces. These results indicate that the volume of 10 ml is suitable for an epidural blood patch and it suggests that the patient must be placed in a supine or lateral position immediately after an epidural blood patch is done because of the equalizing of the pressure difference. However, there was still a small difference in pressure between the two compartments: The CSF pressure being higher than the epidural pressure.
Blood Patch, Epidural ; Cerebrospinal Fluid ; Cerebrospinal Fluid Pressure ; Epidural Space ; Headache ; Humans ; Hypovolemia ; Injections, Epidural ; Lidocaine ; Recurrence

BACKGROUND: One of the most serious risks of epidural anesthesia is total spinal blockade from unintentional dural puncture. We evaluated the glucose test and the thiopental precipitation test to differentiate cerebrospinal fluid (CSF) from local anesthetics (LA). METHODS: (1) Experiment 1: CSF from twenty patients was serially diluted with 2% lidocaine or 0.5% bupivacaine. The ratio of CSF to LA-CSF mixture (CSF/(LA+CSF)) was from 0 to 1.0 at an interval of 0.1. We measured the glucose level of each sample with blood sugar meter. (2) Experiment 2: CSF from a hydrocephalus patient was serially diluted and its glucose level of each sample was measured in the same way as Experiment 1. We performed a urine stick test with each sample. Ten anesthetists blinded to the nature of the sample were asked to identify the results of the tests. (3) Experiment 3: Two milimeters of 2.5% thiopental was respectively mixed with local anesthetics, the amount of which was from 0.1 to 1.0 ml at an interval of 0.1 ml. Sixteen anesthetists blinded to the nature of sample were asked to identify the results of the tests. RESULTS: (1) Experiment 1: We can measure glucose level at CSF/(LA +CSF) of 0.5 in 2% lidocaine group and 0.6 in 0.5% bupivacaine group. (2) Experiment 2: We can detect glucose at lower level of CSF/(LA +CSF) by glucose meter than urine stick test (p<0.05). (3) At least 0.35 ml of 2% lidocaine and 0.29 ml of 0.5% bupivacaine was needed respectively to detect precipitation. CONCLUSION: We suggest that blood glucose meter be used instead of glucose test strip. For thiopental precipitation test, we have to adjust the amount of thiopental depending on the amount of test fluid.
Anesthesia, Epidural* ; Anesthetics, Local* ; Blood Glucose ; Bupivacaine ; Cerebrospinal Fluid* ; Glucose ; Humans ; Hydrocephalus ; Lidocaine ; Punctures ; Thiopental

BACKGROUND: One of the most serious risks of epidural anesthesia is total spinal blockade from unintentional dural puncture. We evaluated the glucose test and the thiopental precipitation test to differentiate cerebrospinal fluid (CSF) from local anesthetics (LA). METHODS: (1) Experiment 1: CSF from twenty patients was serially diluted with 2% lidocaine or 0.5% bupivacaine. The ratio of CSF to LA-CSF mixture (CSF/(LA+CSF)) was from 0 to 1.0 at an interval of 0.1. We measured the glucose level of each sample with blood sugar meter. (2) Experiment 2: CSF from a hydrocephalus patient was serially diluted and its glucose level of each sample was measured in the same way as Experiment 1. We performed a urine stick test with each sample. Ten anesthetists blinded to the nature of the sample were asked to identify the results of the tests. (3) Experiment 3: Two milimeters of 2.5% thiopental was respectively mixed with local anesthetics, the amount of which was from 0.1 to 1.0 ml at an interval of 0.1 ml. Sixteen anesthetists blinded to the nature of sample were asked to identify the results of the tests. RESULTS: (1) Experiment 1: We can measure glucose level at CSF/(LA +CSF) of 0.5 in 2% lidocaine group and 0.6 in 0.5% bupivacaine group. (2) Experiment 2: We can detect glucose at lower level of CSF/(LA +CSF) by glucose meter than urine stick test (p<0.05). (3) At least 0.35 ml of 2% lidocaine and 0.29 ml of 0.5% bupivacaine was needed respectively to detect precipitation. CONCLUSION: We suggest that blood glucose meter be used instead of glucose test strip. For thiopental precipitation test, we have to adjust the amount of thiopental depending on the amount of test fluid.
Anesthesia, Epidural* ; Anesthetics, Local* ; Blood Glucose ; Bupivacaine ; Cerebrospinal Fluid* ; Glucose ; Humans ; Hydrocephalus ; Lidocaine ; Punctures ; Thiopental

BACKGROUND: A hypertensive response is seen when a skull pin is inserted for a craniotomy. The risk of morbidity and mortality is high in patients with intracranial pathology. Many methods have been introduced to overcome the problem. We compared the hemodynamic effects and changes of intracranial pressure when we used lidocaine or fentanyl for blunting the hypertensive response. METHODS: Thirty-two patients scheduled for a craniectomy were divided into two groups: an IV (intravenous) bolus of fentanyl (2micro gram/kg) group or lidocaine (1.5 mg/kg) group. An anesthesia was induced with fentanyl (2micro gram/kg), thiopental (5-7 mg/kg), lidocaine (1.5 mg/kg) and vecuronium (0.1 mg/kg), and was maintained with isoflurane 1 MAC (minimum alveolar anesthetic concentration) in nitrous oxide 50% and oxygen. After induction of anesthesia, a lumbar subarachnoid catheter was inserted for CSFP (cerebrospinal fluid pressure) measurement. An IV bolus of either fentanyl (2micro gram/kg) or lidocaine (1.5 mg/kg) was administered prior to insertion of the skull pin by a randomized method. CSFP, MAP (mean arterial pressure), and HR (heart rate) were measured before and 5 min after induction of anesthesia, immediately before and each mininute for five measurements after skull pin insertion. RESULTS: There were no intergroup differences in the values of CSFP and HR. The MAP increased 9+/-14 (mean+/-SD) mmHg and 4+/-12 (mean+/-SD) mmHg 1 min after the skull pin insertion compared with immediately before skull pin insertion in the fentanyl group and lidocaine group respectively. The MAP recovered 2 min after the skull pin insertion in both groups. CPP (cerebral perfusion pressure) recovered 3 min and 2 min after the skull pin insertion in the fentanyl group and lidocaine group respectively. CONCLUSIONS: An IV bolus of either fentanyl or lidocaine before skull pin insertion resulted in a stable value of CSFP, CPP and HR.
Anesthesia ; Catheters ; Cerebrospinal Fluid Pressure* ; Cerebrospinal Fluid* ; Craniotomy ; Fentanyl* ; Hemodynamics ; Humans ; Intracranial Pressure ; Isoflurane ; Lidocaine* ; Mortality ; Nitrous Oxide ; Oxygen ; Pathology ; Perfusion* ; Skull* ; Thiopental ; Vecuronium Bromide

OBJECTIVE: To establish a rapid and simple gas chromatographic-mass spectric method for qualitative and quantitative analysis of lidocaine in blood and cerebrospinal fluid(CSF). METHODS: Following an acidification of HCl, blood or CSF was alkalinized with NaOH (pH=9) and extracted with ether for two times. Evaporated in a water bath and with an air velocity of nitrogen gas, extract was dissolved with ethanol and analyzed by a gas chromatographic-mass spectrum method, lidocaine was analyzed qualitatively and quantitatively by GC/MS (SIM:86, 58, 72, 87). RESULTS: Linear range of lidocaine detected in blood or CSF by this method is 1.0-60.0 microg x mL(-1) (r=0.9999), the minimum detected concentration of lidocaine was 0.02 microg x mL(-1) (S/N=3), recovery is at 85%-103%. This method was used in the determination of lidocaine in dog model died of the anesthesia with lidocaine. CONCLUSION This study provided a gas chromatographic-mass spectric analysis for lidocaine in blood and CSF. This method was more selective, little interferefering, more sensitivities and simpler. It could be used in the detection of lidocaine in biological fluids.
Anesthesia, Epidural ; Anesthetics, Local/cerebrospinal fluid* ; Animals ; Dogs ; Forensic Medicine ; Gas Chromatography-Mass Spectrometry/methods* ; Humans ; Injections, Intravenous ; Lidocaine/cerebrospinal fluid* ; Sensitivity and Specificity

Spinal anesthesia has a rapid onset and requires small doses of local anesthenc to provide reliable surgical anesthesia and good muscular reiaxation but the disadvantages are the unpredictability of upper level of block, precipitous hypotension, inability to extend the block, and the risk of postdural puncture headache. A combined spinalepidural (CSE) technique can be used to reduce or eliminate some of the disadvantages of spinal and epidural anesthesia while preserving their activity. A combined spinalepidural block may combine the reliability of spinal block and the flexibility of epidural block while minimizing their drawbacks. CSE anesthesia was performed in the 19 patients scheduled for elective total knee arthroplasty. At first 17 G Tuohy needle was inserted L2-3 interspace, the epidual space would be identified, and then a long 22 G spinal needle was introduced through the Tuohy needle until the tip of the spinal needle would penetrate the dura. The correct placement of the spinal needle was confirmed by the appearence of cerebrospinal fluid at the head of needle, then 0.5% hyperbaric tetracaine 1.6-2 ml was injected into subarachnoid space. The spinal needle was withdrawn and a 18 G epidural catheter was introduced into the epidural space. If the patients complained pain during operation, 5 ml of 2% lidocaine was injected through epidural catheter, 2.5 mg Morphine was injected into epidural space for postoperative pain control after operation. Operations were well performed under CSE anesthesia and postoperative pain controls were well managed, too. The responses of the patients who has experienced CSE anesthesia were mostly good.
Anesthesia ; Anesthesia, Epidural* ; Anesthesia, Spinal ; Arthroplasty* ; Catheters ; Cerebrospinal Fluid ; Epidural Space ; Head ; Humans ; Hypotension ; Knee* ; Lidocaine ; Morphine ; Needles ; Pain, Postoperative ; Pliability ; Post-Dural Puncture Headache ; Subarachnoid Space ; Tetracaine

BACKGROUND: Epinephrine-containing epidural test dose is used for obstetric epidural anesthesia to identify the unintentional cannulation of an epidural vessel. This study evaluated the effects of an epinephrine test dose during epidural anesthesia with 0.5% ropivacaine in ceasrean section. METHODS: Seventy healthy pregnant women, scheduled for elective cesarean section were randomly assigned to one of two groups. A lumbar epidural catheter was placed and aspirated. If aspiration was positive for blood or cerebrospinal fluid, the catheter was replaced. All patients received an 3 ml test dose of either 1.5% lidocaine with epinephrine 5microgram/ml (group E) or lidocaine only (group C). After test dose, 50microgram fentanyl and 20 ml of 0.5% ropivacaine were given to the all patients. Applying the pin prick method and a modified Bromage scoring system, senseory block level and motot block intensity were checked at 5 min intervals for the first hour following ropivacaine injection. After then, they were checked at 15 min intervals for the rest of the test period. Heart rate (HR) and blood pressure (BP) were measured as well. RESULTS: No significant difference between the two groups was detected in HR, BP, the profile of sensory block, motor scores and the onset of motor block. However, group C showed significantly shorter span of motor block (102 +/- 31 min.) than group E (134 +/- 32 min.) (P <0.05). There was no significant difference in neonatal outcome, as assessed by Apgar score at delivery. The most common adverse effect in mothers was hypotension. No serious adverse effects were detected in this study. CONCLUSIONS: We conclude that only the span of motor block by the epidural ropivacaine is affected by epinephrine-containing epidural test dose.
Anesthesia, Epidural* ; Apgar Score ; Blood Pressure ; Catheterization ; Catheters ; Cerebrospinal Fluid ; Cesarean Section ; Epinephrine ; Female ; Fentanyl ; Heart Rate ; Humans ; Hypotension ; Lidocaine ; Mothers ; Pregnancy ; Pregnant Women

There have been cases reported of pneumocephalus, spinal cord and nerve root compression associated with the use of air in the loss of resistance technique during epidural block. However, the manual loss of resistance technique is still widely used by anesthesiologists for identifying the epidural space. A 65-yr-old female requested epidural steroid injection for her low leg radiating pain. A 22-guage Tuohy needle was placed in the L3-4 interspace with the loss of resistance technique using 4 ml air. Aspiration yielded no cerebrospinal fluid. After injection of 1% lidocaine 5 ml as a test dose, 0.25% lidocaine 10 ml with 40 mg triamcinole was infused and she did not show any abnormal signs. After changing to sitting position, however, the patient complained of increasing headache and nausea. After vomiting, she was obtunded. CT scan showed brainstem compression by the air. The patient lost conscioussness for 20 minutes. Four hours later, her neurologic examination was normal except for the headache. She was discharged on the third day after the accident and the headache subsided by the fifth day. As far as we know, this is the first case reported of a brain stem compression by air after epidural technique that induced serious neurologic symptoms.
Brain Stem* ; Cerebrospinal Fluid ; Epidural Space ; Female ; Headache ; Humans ; Leg ; Lidocaine ; Nausea ; Needles ; Neurologic Examination ; Neurologic Manifestations ; Pneumocephalus ; Radiculopathy ; Spinal Cord ; Tomography, X-Ray Computed ; Vomiting