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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 discus-

sion 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 d iscussing 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 under-

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

2 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

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 con-

sent, 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 75mg

bupivacaine and 100cg fentanyl, Group BFK received 30mg 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

BF BFK P

Onset of sensory block (minute) 2,9 1 2,3 0,5 0,068

Two segment regression time (minute) 197,7 28 121 42 0,001

Duration of sensorial block (minute) 252,5 25 213,5 23 0,001

Maximum level of sensory block T6(T4T6) T2(T2T4) 0,001

Conclusions: Preoperative use of epidural ketamine antagonizes the bene-

ficial 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. HakobyanAnaesthesiology 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 intraabdomi-

nal 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 postop-

erative 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 catheter-

ization was performed at Th8Th10 level. After test dose and correct place-

ment 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 wasmeasured transvesically after instillation of 50ml 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 inva-

sively 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 3.006mmHg vs.

7.727 3.439 mmHg (p 0.0001); 63.732 16.244mmHg vs. 75.658

18.986 mmHg (p 0.005) and 77.641 17.398mmHg 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.

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 conven-

tional EA for ambulatory pilonidal sinus (PS) surgery.

Local and regional anaesthesia 87