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Approximately 75% of patients diagnosed with bacterial endocarditis have a pre-existing cardiac abnormality discount advair diskus amex asthma symptoms home remedies. Rheumatic heart disease is the most common anatomical condition 10 Infectious Complications in Infective Endocarditis 125 A Fig buy 100mcg advair diskus otc childhood asthma definition. A vast array of structural complications may ensue and can result in signiļ¬cant hemodynamic consequences to the patient advair diskus 500 mcg without prescription asthma definition 2014. The valve leaļ¬ets are usually affected, but the other structures can also be involved including the chords, myocardium, perivalvular tissue and implanted leads or conduits. In the acute settings, vegetations lead to leaļ¬et erosion or chordal rup- ture due to their predilection to the leaļ¬et closure region resulting in valvular regur- gitation. With proper medical treatment, vegetations generally regress with time and become more echodense, in tandem with a dramatic decrease in the embolic risk. Nonetheless <10 % of the affected valves retains normal morphology and func- tion, and the vast majority develop regurgitation due to the development of ļ¬brosis, leaļ¬et retraction and nodular calciļ¬cation. Valvular stenosis is uncommon, but can be present in patients with large vegetations usually caused by Staphylococcus aureus or fungi [8 ]. Regurgitation in this setting is usually eccentric with the origin of the regurgitation jet away from the site of leaļ¬et coaptation. Leaļ¬et perforation particularly with the mitral valve occurs in the setting of valvular aneurysm or diverticulum (Figs. Thus, if a leaļ¬et aneurysm or diverticulum is present, perforation within the structure should be sought. In patients in whom the infection has responded to medical treatment, valvular perfo- ration may be amenable to patch repair. Left sided regurgitant lesion may result in signs of left heart failure and pulmonary congestion, which are negative prognosticators in patients with endocarditis [12, 13]. Acute valvular insufļ¬ciency may present with signs of cardiogenic shock without a prominent murmur due to rapid equalization of pressure between the aorta and left ventricle in the case of aortic regurgitation and left ventricle and the left atrium in the case of mitral regurgitation. Tricuspid regurgitation is the most frequent right-sided valve lesion but rarely causes signiļ¬cant hemodynamic consequences by itself [14, 15 ]. Long standing severe tricuspid regurgitation may result in signs of right heart failure such as peripheral edema, pleural effusion and ascites. The pulmonic valve is rela- tively spared from infection with the exception of predisposing factors such as the tetralogy of Fallot or rheumatic heart disease [16 ]. Multiple mechanisms can be responsible for valvular regurgitation and often depend on the site of infection. Damage to supporting structures, such as chords, can result in chordal rupture with ļ¬ail leaļ¬et. Direct infection of the leaļ¬et surface can result in the formation of diverticula that may predispose to leaļ¬et perforation while damage to the leaļ¬et tips may result in malcoaptation that can create a regur- gitant oriļ¬ce . Valvular Stenosis Endocarditis causing valvular stenosis is less frequently encountered than valvular regurgitation. Prosthetic valves may become stenotic if large vegetations impact opening of the valve poppets and result in mechanical failure. Acute valve stenosis can result in heart failure or shock and could be accompanied by a systolic or diastolic murmur depending on the valve involved. Subacute stenosis may present with more gradual onset of symptoms with similar auscultatory ļ¬ndings. The risk factors associated with the development of perivalvular abscess are listed in Table 10. The periannular infec- tion leads to necrosis and weakening of the adjacent tissue. Serial echocardiographic studies have demonstrated liquefaction and expansion of the perivalvular abscess, followed by cavitation and/or ļ¬stula communications or even drainage into the peri- cardial space [20, 21] (Fig. Transesophageal echocardiography was used to diagnose abscess and to fol- low-up the subsequent evolution of the perivalvular complications. Perivalvular complications such as pseudoaneurysms and ļ¬stulae developed in all the medically treated patients and in 10 of the 24 surgically treated patients [20 ]. These patients have a high incidence of perivalvular complication despite early Table 10. They need to be closely monitored for evolution of the perivalvular infection process, even after surgical intervention. Two weeks later the long-axis (c) and short-axis (d) views show cavitation of the abscess to become a pseudoa- neurysm (arrow) which communicates with the left ventricular outļ¬ow tract. The diagnosis of fungi and less common microorganisms depends on astute clinical judgement and the result of serial blood cultures on speciļ¬c media, although diagnostic imaging may occasionally gives clues to the etiologic agent. Pseudoaneurysm When an abscess begins to cavitate and expand, the weakened tissue may rupture and drain into the surrounding structures, resulting in the formation of pseudoaneu- rysm or ļ¬stula [20, 21] (Fig. In the case of periaortic abscess, communi- cation with the aortic root is more likely than with the left ventricular outļ¬ow tract . Fistula communication between the aorta and any of the four cardiac chambers can occur dependent on which of the aortic sinuses is involved by the abscess. We have observed that a perivalvular abscess can cavitate within 2 weeks and evolve into a pseudoaneurysm as early as 4 weeks following diagnosis [20 ]. Pseudoaneurysm is a pulsatile structure with an echolucent cavity that may contain debris associated with ongoing infection. In patients with periaortic abscess, the central posi- tion of the aortic root enables ļ¬stula communication with any of the four cardiac chambers (Fig. Fistula formation is an indication of extensive tissue dam- age and not surprisingly half of the patients with aortic ļ¬stula would also have moderate or severe aortic regurgitation . Patients with ļ¬stula have a higher inci- dence of congestive heart failure and a reduced survival, necessitating a greater need for surgical intervention [26, 27 ]. Destruction of the sewing ring may compromise the attachment of the prosthesis to the surrounding annulus. Perivalvular ļ¬stula may form in such situations and the patientās condition may range from clinically stable to cardiogenic shock from acute severe perivalvular insufļ¬ciency . Reinfection is always a concern in this situation but non-infectious valve dehiscence is not uncommon in this clinical setting due to the friability of the annular tissue which does not allow secure anchoring of the sutures [29ā32]. Although trivial or mild perivalvular regur- gitation immediately post implant tends not to affect long term prognosis, signiļ¬- cant leak may result in heart failure and the need for reoperation [29 , 31]. Related Complications Other serious complications may occur due to the perivalvular complications. The development of heart block is an indication of a periaortic abscess invading into the adjacent conduction system. Extension or rupture into the pericardial space leading to cardiac tamponade is another rare but life threatening complica- tion . Imaging Echocardiography Echocardiography is a powerful tool for diagnosing perivalvular complications and 3-dimensional echocardiography has emerged as a promising imaging modality. Echocardiography is portable, relatively inexpensive and does not involve the use of ionizing radiation. Temporal and spatial resolution of ultrasound is high allowing visualization of small highly mobile vegetations.
A special clinical challenge presents when surgery requires an intense (profound) or deep level of intraoperative block (see Reversal of Intense (Profound) Neuromuscular Block) (Table 21-12) purchase advair diskus 250mcg with amex neutrophilic asthma definition. At this level of block buy advair diskus 250mcg amex asthma treatment ems, reversal may be achieved with a medium dose of sugammadex (4 mg/kg) purchase advair diskus 100 mcg with amex asthma humidity. There are three clinically available acetylcholinesterase inhibitors (anticholinesterase agents) in clinical use today: neostigmine, edrophonium, and pyridostigmine. These cholinesterase inhibitors are quaternary compounds and do not cross the bloodābrain barrier in sufficient concentrations to have central effects. Their duration of action, at equivalent doses, is similar (60 to 120 minutes), but onset of action is fastest for edrophonium, intermediate for neostigmine, and longest for pyridostigmine. Physostigmine, another cholinesterase inhibitor, is a tertiary amine, but because it crosses the bloodābrain barrier (and has central effects), it is not used for pharmacologic reversal of neuromuscular block. Edrophonium, similar to all cholinesterase inhibitors, is ineffective in reversing deep block, and it is used infrequently as a first-line agent, unless other agents are unavailable (see Drug Shortages and Clinical Impact). Because of its longer onset time than neostigmine, pyridostigmine is used rarely in anesthesia practice to antagonize neuromuscular block; it is used most often as an oral cholinesterase inhibitor for the treatment of myasthenia gravis. Neostigmine is the most frequently used anticholinesterase agent today, although a new, more effective agent recently has been approved in the United States (see Selective Relaxant Binding Agents). Neostigmineās inhibitory effects are concentration dependent, and at higher concentrations (>2. For this reason, they are generally coadministered with either glycopyrrolate (which has a slower onset of action similar to neostigmine) or atropine (which has a more rapid onset of action similar to edrophonium). Increasing the dose beyond 70 Ī¼g/kg is not recommended, as this dose may induce neuromuscular dysfunction. Similarly, administration of even small doses of neostigmine (30 Ī¼g/kg) at a time when recovery of neuromuscular function is almost complete may produce upper airway collapse and may decrease the activity of the genioglossus muscle. However, there are currently few if any data on the effectiveness or safety of routine neostigmine use in the pediatric population. If neostigmine is administered at a deep block, the initial rapid recovery will occur during a blind period, when no responses are possible (or visible), followed by a slow and prolonged recovery at shallower depths of block. Attempts at pharmacologic reversal using doses of neostigmine larger than 70 Ī¼g/kg or using a combination of cholinesterase inhibitors (e. When the neostigmine dose was increased to 40 Ī¼g/kg and 80 Ī¼g/kg (a dose that is currently not recommended for use, regardless of the depth of neuromuscular block), the recovery times were 3. A similar dose of neostigmine (20 Ī¼g/kg) was found effective in reversing rocuronium-induced minimal block. These factors underscore and explain why neostigmine-induced reversal of deep block may take upwards of 300 minutes, as recovery from this depth of block is mostly driven by spontaneous recovery. Reversal with neostigmine was either spontaneous or neostigmine was administered 5 minutes after rocuronium (no twitch), or at 1% twitch recovery (T1 1%), or at 25% twitch recovery (T1 25%). Time is shorter when neostigmine is given at T1 25%, than it is at reappearance of T1. Early and late reversal of rocuronium and vecuronium with neostigmine in adults and children. It should be pointed out, however, that the conclusion that neostigmine 10 Ī¼g/kg is effective in antagonizing this level of block is based on data from 12 patients; outlier patients who might require significantly longer recovery times are likely. Since there are no data to unequivocally demonstrate the reliability of a 10 Ī¼g/kg dose of neostigmine for reversal of light or minimal neuromuscular block, neostigmine doses of less than 20 Ī¼g/kg cannot be recommended. Regardless of when administered, neostigmine-induced reversal is always faster than spontaneous recovery. Larger doses of neostigmine will also be more effective than lower doses in effecting neuromuscular block reversalā within the dose ranges in which neostigmine is effective (i. Other Effects Neostigmine (and the other anticholinesterases) induce vagal stimulation, so anticholinergic agents are usually coadministered. Atropine is faster in onset than glycopyrrolate, produces more tachycardia, and crosses the bloodābrain barrier. It is slower in onset and induces less tachycardia; for these reasons, it is preferred especially in patients with coronary artery disease. Similarly, treatment with magnesium sulfate will slow neostigmine-induced spontaneous recovery. More significant effects on respiratory function were reported when neostigmine was administered after full recovery from neuromuscular block; there was a significant impairment of the upper airway dilator ability as a result of impaired genioglossus muscle and diaphragmatic function. The only remaining variable is the appropriateness of neostigmine administration as it relates to timing and dose. At this depth of block, neostigmine will be ineffective, and should not be administered. However, in these circumstances, doses of neostigmine of 20 to 30 Ī¼g/kg are sufficient to reliably assure satisfactory return of neuromuscular function within approximately 10 minutes (Fig. While these guidelines may offer the clinician some broad parameters for improving the efficacy of pharmacologic reversal using cholinesterase inhibitors based on subjective evaluation of neuromuscular function, an optimal reversal strategy can only be assured if clinical decisions are based on quantitative assessment of the depth of neuromuscular block (see Monitoring Neuromuscular Blockade). As already noted, subjective (tactile, visual) assessment and clinical testing are inadequate substitutes for objective (quantitative) monitoring. Drug Shortages and Clinical Impact Drug shortages have existed for decades, but the number of drugs on the shortage list and the duration of shortages have increased significantly in the last decade. In many clinical settings, the disappearance from the market of generic (and much less expensive) neostigmine has forced clinicians to seek alternative cholinesterase inhibitors, including edrophonium. Dosing recommendations for administration of cholinesterase antagonism (neostigmine) are shown on the x-axis at four depths of neuromuscular block. Edrophonium Edrophonium is an anticholinesterase agent that is used clinically for reversal of nondepolarizing neuromuscular block. It is much faster in onset and to peak antagonism (1 to 2 minutes) than neostigmine (7 to 11 minutes) or pyridostigmine (12 to 16 minutes). The administration of the combination drug in divided doses over several minutes, as opposed to rapid bolus administration, will result in a lower peak plasma concentration of both agents, and will minimize the potential for bradycardia (from edrophonium) or tachycardia (from atropine). Binding to rocuronium is extremely tight, with no clinically relevant dissociation (dissociation constant estimate of 0. When this occurs, there is normalization of neuromuscular function (pharmacologic reversal). Pharmacology Sugammadex is highly water soluble and initial studies have shown it to be devoid of the side effects associated with the use of cholinesterase inhibitors and muscarinic antagonists. The speed of reversal is dose dependent, and in general, larger sugammadex doses will hasten recovery. Sugammadex (in rhesus monkey) also rapidly and effectively antagonizes the main metabolite of vecuronium, 3-desacetyl vecuronium, at a dose (0. Metabolism of sugammadex is very limited, and it is eliminated primarily via renal excretion. In patients with severe renal impairment, both sugammadex and the sugammadex/rocuronium complex may be effectively removed with hemodialysis using a high-flux dialysis method.
If no tumor of the adenoma purchase genuine advair diskus line asthma symptoms 33, and with further incisions in the capsule is seen purchase advair diskus asthma definition yoga, the lateral surfaces of the anterior lobe are then in- of the pituitary gland just beyond the tumor margin to re- spected by passing a disk dissector outside the capsule of lease tension on the tumor as the dissection proceeds discount advair diskus 500mcg fast delivery asthmatic bronchitis zinc. A the pituitary, between the lateral margin of the gland and small Hardy sucker (2-mm tip) on the margin of a cotton the lateral dural wall of the sella (the medial wall of the cav- pad is used to provide separation of the interface between ernous sinus). Using fne-tipped bipolar forceps, this space the gland and the adenoma for dissection and for sponging can be dissected superfcially and then more deeply until the small amount of bleeding out of the feld of view. After these two tissues posterior margin of the adenoma often requires dissection have been separated, small pieces of Gelfoam are packed using a disk dissector and a small or medium ring curette. After both lateral surfaces are pressure that is applied is directed at the dissection plane, exposed and examined in this fashion, the inferior surface slightly more toward the gland than the adenoma. If a tumor can be margins of the tumor have been completely dissected, to identifed from inspection of the surface, it is removed as prevent rupture of the tumor, the last remaining connec- described. If no tumor is identifed on inspection of the su- tion between the pseudocapsule of the specimen and the perfcial gland, a series of vertical incisions is then made, pituitary capsule is grasped with a small cup forceps and each of which begins 1 to 2 mm below the superior edge of the tumor is removed. In cases of tumors 8 to 10 mm or less the pituitary exposure and is directed downward, initially in diameter, the entire tumor can usually be shelled out of to a depth of only approximately 1 mm, and then in stages its bed in the anterior lobe as an intact specimen. Successful deeper through the anterior lobe until either the intermediate 114114 Endoscopic Pituitary SurgeryEndoscopic Pituitary Surgery Fig. The which these two layersāthe surface of the pituitary and the dura ma- goal of the exploration is to fnd and identify the distinct encapsu- terāare most tenaciously attached to each other. Success depends on beginning with a identifed from inspection of the surface, it is removed as described widely exposed, bloodless surgical feld (A). If no tumor is identifed on rior and inferior sella dura is avoided during the exposure and dural inspection of the superfcial gland, a series of vertical incisions is then opening because it would produce a white area on the surface of the made (B), each of which begins 1 to 2 mm below the superior edge of underlying gland that may falsely suggest the site of the adenoma. Because the pituitary surfaces are carefully inspected for regions of focal discoloration. The blood supply and the delivery of hypothalamic trophic factors to the adenoma usually appears to be grayāblue or yellowāwhite, and can be pituitary are oriented vertically, vertical incisions should be less likely identifed against the background of the anterior lobe surface whose to cause an infarction in a portion of the pituitary or to isolate the color is orangeāpink. For this the lateral dural wall of primary object of the search, with the intent to identify the margin of the sella (the medial wall of the cavernous sinus) is separated from the tumor before entering it and spilling its contents, by using the sur- the pituitary capsule by gently passing a disk dissector between these gical capsule of the adenoma (B,C). The space produced provides room adenoma is identifed, the tumor is removed using dissection along for dissection of the interface between the lateral pituitary capsule the interface of the adenoma and the normal gland, as described in and the dural wall with the closed tips of a fne-tipped bipolar forceps Fig. Dissection is initially superfcial and then progresses in stages to terior lobe, a 2-mm-wide slice of the anterior lobe may be removed to deeper levels until the posterior sella has been reached. After these provide space for dissection and removal of the deep microadenoma two tissues have been separated, small pieces of Gelfoam are packed (not shown). Development of a his- into the intervening space to rotate the lateral surface anteriorly and tological pseudocapsule and its use as a surgical capsule in the exci- to gently displace it medially into the surgeonās direct view. Reprinted with lateral surfaces are exposed and examined in this fashion, the inferior permission. Long-term results are as yet un- capsule of the tumor without penetrating it and spilling its established. With the capsule exposed, the tumor is removed approach reported remission rates of 77 and 80%. We emphasize that and contained within the anterior lobe of the gland, con- all these series included only a small number of patients ventional microsurgical technique, in which an incision is and have limited follow-up, and the recurrence rates are made in the tumor and the tumor is removed from within, unknown. Hofmann et al27 in 2008 reported their long-term results for the microsurgical tech- nique. They assessed their results in 426 primary operations I Postoperative Assessment over 35 years. Immediate remission of hypercortisolism was achieved in 292 of the 426 operations (69%). In patients in To determine the success of surgery during the immediate whom an adenoma was identifed and removed, after se- postoperative period, replacement therapy is not adminis- lective adenomectomy the remission rate was 75. This tered, and serum cortisol levels are obtained while the patient rate showed no improvement over the years. The recurrence cortisolism, patients begin to receive replacement hydro- rate (15%) and the complication rate (5. If no adenoma was found, exploration of the sella success provides the surgeon with the potential to ofer early turcica was performed in 45. Because it takes several months for the hypothalamic- with microadenomas, surgical remission was achieved in pituitary-adrenal axis to recover, these patients require replace- 86%. These symptoms include lethargy, to have a recurrence than patients who had a serum cortisol headache, anorexia, and abdominal discomfort or nausea. The patientās blood pressure is normal or even low, and pa- Using the pseudocapsular extraction technique described tients who have previously been hypertensive may need to for encapsulated adenomas, Oldfeldās group3 achieved 100% stop the antihypertensive medications. Similarly, because resolution of hypercortisolism in 261 patients prior to hos- glycemic control may be restored after surgery, preopera- pital discharge. After a mean clinical follow-up of 84 months discharged with daily physiologic cortisol replacement, ad- (range 12ā215 months), six patients (2. A popular choice of hypercortisolism but all were successfully retreated with is hydrocortisone, 15 to 20 mg in the morning and 5 mg in surgery. These results imply that the use of the pseudocap- the evening, until normal function of the hypothalamic- sule allows reliable identifcation of the tumor at surgery pituitary-adrenal axis is reestablished. Three (13%) of the 24 patients who were in remission from hypercortisolism following repeat surgery developed recurrent hypercortisolism 10 to 47 months postoperatively. No patient had a relapse during a median follow- should be considered in certain circumstances. Cerebrospinal fuid leakage occurred in six eration (within 1ā6 weeks) can induce remission in many patients, and 11 patients required hormonal replacement therapy after surgery. Patients who have undergone lim- most commonly the cavernous sinus wall contiguous to the ited exploration of the pituitary and selective excision former location of the adenoma. In the series of Dickerman and Oldfeld,36 repeated surgery (44 Ā± 35 months after the of an area that at surgery appeared to be, but proved not to have been, an adenoma also are good candidates for initial surgery) in all 43 patients in whom tumor had been repeat surgery. However, patients who had an exten- identifed at the initial surgery, the tumor was found at the sive exploration and partial resection of the anterior same site or contiguous to the same site. In addition, 39 (93%) surgery warrants consideration, especially when prompt of the 42 invasive adenomas were located laterally and in- control of hypercortisolism is required. Overall adenoma invasion of the dura mater was found in 31 (54%) of 57 microadenomas and in all 11 macroadenomas at repeated surgery. At repeated surgery the tailing the results of transsphenoidal surgery in 31 patients residual tumor can be found at, or immediately contiguous who had previously undergone a transsphenoidal opera- to, the site at which the tumor was originally found. Thus, tion and two patients who had had previous pituitary ir- unappreciated dural invasion with growth of residual tumor radiation only, in 24 (73%) of the 33 patients, remission of within the cavernous sinus dura, which frequently occurs hypercortisolism was achieved by surgery. The incidence of Therefore, repeat transsphenoidal exploration of the pi- remission of hypercortisolism was greatest if an adenoma tuitary and treatment limited to selective adenomectomy was identifed at surgery and the patient received selec- should be considered in patients with hypercortisolism de- tive adenomectomy (19 [95%] of 20 patients), if there was spite previous pituitary treatment. Fractionated radiation of the sella after failed transsphenoi- dal surgery achieves biochemical remission in most patients 38 References (80% at 4 years). Because remission is delayed 6 months to several years after radiation therapy, medical therapy is 1. Development of a histological pseudo- expected side efect, but it usually occurs 5 to 10 years af- capsule and its use as a surgical capsule in the excision of pituitary ter treatment and does not occur in all patients.
In addition buy genuine advair diskus line baby asthma symptoms uk, anesthesiologists using palpation often misidentify the lumbar interspaces and end up inserting needles at a higher level than intended advair diskus 500mcg low price asthma definition medical. Intentional lateral approaches generic advair diskus 100 mcg otc asthma high altitude, for example, transforaminal approach (needle D), have the potential to come in close proximity to the spinal nerve or a spinal artery. Note that transforaminal approaches are typically at the cervical or lumbar levels, not the T6 level as illustrated. Anatomy and pathophysiology of spinal cord injury associated with regional anesthesia and pain medicine: 2015 update. The cervical epidural space is narrow and the underlying spinal cord is vulnerable to needle trauma. Injury associated with cervical epidural injection was the most common damaging event in a recent review of pain medicine malpractice claims. Cervical epidural injections represent fewer than one-quarter of epidural injections but generate two-thirds of epidural injection related claims. Abscess and hematoma are the most widely studied compressive complications of neuraxial block. Significant hematoma may occur as often as 1:3,600 blocks or as rarely as 1:260,000. The American Society of Regional Anesthesia has a regularly updated guideline (www. Epidural abscess is less common, complicating approximately 1:100,000 2330 neuraxial blocks. Rarely, the combination of neuraxial local anesthetics and other mass lesions (tumors, lipomas, cysts, or granulomas) can produce compressive symptoms (Fig. Other worrisome signs are persistent or recurrent sensory or motor block and bowel or bladder dysfunction. Complete or partial neurologic recovery seems most likely if surgical decompression occurs within 8 to 12 hours of symptom onset. Spinal cord ischemia or infarction related to systemic hypotension also is unusual. However, there are cases of ischemic spinal cord injury attributed to a prolonged period of hypotension. Current guidelines, based only on expert opinion, suggest keeping blood pressure within 20% to 30% of baseline. Also, hypertrophy of the ligamentum flavum and bony elements of the spinal canal can reduce spinal canal cross-sectional area, limiting space for the spinal cord and nerve roots. Spinal stenosis, combined with degenerative narrowing of the intervertebral foramina, may lead to increased vertebral canal pressure and decreased spinal cord blood flow after neuraxial injection of local anesthetics. Currently, it is unclear if worsening neurologic symptoms after neuraxial block in patients with spinal stenosis represents an effect of the anesthetic or the progression of the underlying disease. These nerve roots travel long distances within the spinal canal and are not extensively myelinated. In the 1980s, a series of cases implicated unrecognized intrathecal injection of 2-chloroprocaine as a cause of cauda equina syndrome or adhesive arachnoiditis. Most, but not all, laboratory studies attributed this complication to the sodium bisulfate preservative. Injecting hyperbaric local anesthetic through a caudally directed, side-holed, pencil- point needle also can cause sacral pooling of drug. Most anesthesiologists have abandoned the use of lidocaine for subarachnoid anesthesia. Transient neurologic symptoms are much less common after other intrathecal local anesthetics. Neuraxial anesthesia for the prevention of postoperative mortality and major morbidity: an overview of Cochrane Systematic Reviews. Comparative effectiveness of regional versus general anesthesia for hip fracture surgery in adults. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Impact of regional versus general anesthesia on the clinical outcomes of patients undergoing major lower extremity amputation. Regional versus general anesthesia in surgical patients with chronic obstructive pulmonary disease: Does avoiding general anesthesia reduce the risk of postoperative complications? Neuraxial anesthesia decreases postoperative systemic infections risk compared with general anesthesia in knee arthroplasty. Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty. Regional anaesthesia for hip fracture surgery is associated with significantly more peri-operative complications compared with general anaesthesia. Thromboembolism after total hip replacement: role of epidural and general anesthesia. One-week postoperative patency of lower extremity in situ bypass graft comparing epidural and generalanesthesia: retrospective study of 822 patients. The effects of perioperative regional anesthesia and analgesia on cancer recurrence and survival after oncology surgery. Computerized tomography, clinical and X-ray correlations in the hemisacralized fifth lumbar vertebra. Ultrasound assessment of the vertebral level of the intercristal line in pregnancy. Epidural, cerebrospinal fluid, and plasma pharmacokinetics of epidural opioids (Part 1). New perspectives in the microscopic structure of human dura mater in the dorsolumbar region. Structure of the arachnoid layer of the human spinal meninges: a barrier that regulates dural sac permeability]. Ultrastructural findings in human spinal pia mater in relation to subarachnoid anesthesia. Transventricular and transpial absorption of cerebrospinal fluid into cerebral microvessels. Cerebrospinal fluid volume and nerve root vulnerability during lumbar puncture or spinal anaesthesia at different vertebral levels. Lumbar neuraxial ultrasound for spinal and epidural anesthesia: A systematic review and meta-analysis. Locating the epidural space in obstetric patientsāultrasound a useful tool: Continuing professional development. Neuraxial techniques for labor analgesia should be placed in the lateral position (Con).