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  1. Article ; Online: Failed spinal anaesthesia: mechanisms, management, and prevention.

    Fettes, P D W / Jansson, J-R / Wildsmith, J A W

    British journal of anaesthesia

    2009  Volume 102, Issue 6, Page(s) 739–748

    Abstract: Although spinal (subarachnoid or intrathecal) anaesthesia is generally regarded as one of the most reliable types of regional block methods, the possibility of failure has long been recognized. Dealing with a spinal anaesthetic which is in some way ... ...

    Abstract Although spinal (subarachnoid or intrathecal) anaesthesia is generally regarded as one of the most reliable types of regional block methods, the possibility of failure has long been recognized. Dealing with a spinal anaesthetic which is in some way inadequate can be very difficult; so, the technique must be performed in a way which minimizes the risk of regional block. Thus, practitioners must be aware of all the possible mechanisms of failure so that, where possible, these mechanisms can be avoided. This review has considered the mechanisms in a sequential way: problems with lumbar puncture; errors in the preparation and injection of solutions; inadequate spreading of drugs through cerebrospinal fluid; failure of drug action on nervous tissue; and difficulties more related to patient management than the actual block. Techniques for minimizing the possibility of failure are discussed, all of them requiring, in essence, close attention to detail. Options for managing an inadequate block include repeating the injection, manipulation of the patient's posture to encourage wider spread of the injected solution, supplementation with local anaesthetic infiltration by the surgeon, use of systemic sedation or analgesic drugs, and recourse to general anaesthesia. Follow-up procedures must include full documentation of what happened, the provision of an explanation to the patient and, if indicated by events, detailed investigation.
    MeSH term(s) Anesthesia, Spinal/adverse effects ; Anesthesia, Spinal/methods ; Anesthetics, Local/administration & dosage ; Humans ; Medical Errors/prevention & control ; Spinal Puncture/adverse effects ; Treatment Failure
    Chemical Substances Anesthetics, Local
    Language English
    Publishing date 2009-06
    Publishing country England
    Document type Journal Article ; Review
    ZDB-ID 80074-0
    ISSN 1471-6771 ; 0007-0912
    ISSN (online) 1471-6771
    ISSN 0007-0912
    DOI 10.1093/bja/aep096
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  2. Article ; Online: Spinal anaesthesia for elective surgery: a comparison of hyperbaric solutions of racemic bupivacaine, levobupivacaine, and ropivacaine.

    Luck, J F / Fettes, P D W / Wildsmith, J A W

    British journal of anaesthesia

    2008  Volume 101, Issue 5, Page(s) 705–710

    Abstract: ... in the ropivacaine group was more rapid as demonstrated by duration at T10 (P<0.0167) and total duration of sensory ... block (P<0.0167). Patients in the ropivacaine group had more rapid recovery from motor block (P<0.0167 ... and shorter times to independent mobilization (P<0.0167). There were no significant differences ...

    Abstract Background: The aim of this study was to compare the clinical effects of 'hyperbaric' bupivacaine for spinal anaesthesia with those of similar preparations of levobupivacaine and ropivacaine.
    Methods: Sixty ASA grade I-II patients undergoing elective surgery under spinal anaesthesia were randomized to receive 3 ml of bupivacaine, levobupivacaine, or ropivacaine, each at 5 mg ml(-1) and made hyperbaric by the addition of glucose 30 mg ml(-1). A standard protocol was followed after which a blinded observer assessed the sensory and motor blocks. The level and duration of sensory (pinprick) block, intensity and duration of motor block, and time to mobilize and to micturate were also recorded.
    Results: One patient (ropivacaine group) required general anaesthesia because of technical failure, but all the other blocks were adequate. There were no significant differences between the groups with regard to the mean time to onset of sensory block at T10, the extent of spread, or mean time to maximum spread. Regression of sensory block in the ropivacaine group was more rapid as demonstrated by duration at T10 (P<0.0167) and total duration of sensory block (P<0.0167). Patients in the ropivacaine group had more rapid recovery from motor block (P<0.0167) and shorter times to independent mobilization (P<0.0167). There were no significant differences between the bupivacaine and the levobupivacaine groups.
    Conclusions: 'Hyperbaric' ropivacaine provides reliable spinal anaesthesia of shorter duration than bupivacaine or levobupivacaine, both of which are clinically indistinguishable. The recovery profile of ropivacaine may be useful where prompt mobilization is required.
    MeSH term(s) Adult ; Aged ; Amides/administration & dosage ; Amides/adverse effects ; Anesthesia, Spinal/adverse effects ; Anesthesia, Spinal/methods ; Anesthetics, Local/administration & dosage ; Anesthetics, Local/adverse effects ; Bupivacaine/administration & dosage ; Bupivacaine/adverse effects ; Bupivacaine/analogs & derivatives ; Double-Blind Method ; Drug Administration Schedule ; Elective Surgical Procedures ; Female ; Humans ; Male ; Middle Aged ; Prospective Studies ; Sensation/drug effects ; Specific Gravity
    Chemical Substances Amides ; Anesthetics, Local ; ropivacaine (7IO5LYA57N) ; levobupivacaine (A5H73K9U3W) ; Bupivacaine (Y8335394RO)
    Language English
    Publishing date 2008-11
    Publishing country England
    Document type Comparative Study ; Journal Article ; Randomized Controlled Trial
    ZDB-ID 80074-0
    ISSN 1471-6771 ; 0007-0912
    ISSN (online) 1471-6771
    ISSN 0007-0912
    DOI 10.1093/bja/aen250
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  3. Article: Somebody else's nervous system.

    Fettes, P D W / Wildsmith, J A W

    British journal of anaesthesia

    2002  Volume 88, Issue 6, Page(s) 760–763

    MeSH term(s) Anesthesia, Obstetrical/adverse effects ; Anesthesia, Spinal/adverse effects ; Anesthesia, Spinal/instrumentation ; Anesthesia, Spinal/methods ; Female ; Humans ; Pregnancy ; Spinal Cord Injuries/etiology
    Language English
    Publishing date 2002-04-30
    Publishing country England
    Document type Editorial ; Review
    ZDB-ID 80074-0
    ISSN 1471-6771 ; 0007-0912
    ISSN (online) 1471-6771
    ISSN 0007-0912
    DOI 10.1093/bja/88.6.760
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  4. Article ; Online: Abnormal Functional Connectivity of Frontopolar Subregions in Treatment-Nonresponsive Major Depressive Disorder.

    Fettes, Peter W / Moayedi, Massieh / Dunlop, Katharine / Mansouri, Farrokh / Vila-Rodriguez, Fidel / Giacobbe, Peter / Davis, Karen D / Lam, Raymond W / Kennedy, Sidney H / Daskalakis, Zafiris J / Blumberger, Daniel M / Downar, Jonathan

    Biological psychiatry. Cognitive neuroscience and neuroimaging

    2017  Volume 3, Issue 4, Page(s) 337–347

    Abstract: Background: Approximately 30% of patients with major depressive disorder develop treatment-nonresponsive depression (TNRD); novel interventions targeting the substrates of this illness population are desperately needed. Convergent evidence from lesion, ... ...

    Abstract Background: Approximately 30% of patients with major depressive disorder develop treatment-nonresponsive depression (TNRD); novel interventions targeting the substrates of this illness population are desperately needed. Convergent evidence from lesion, stimulation, connectivity, and functional neuroimaging studies implicates the frontopolar cortex (FPC) as a particularly important region in TNRD pathophysiology; regions functionally connected to the FPC, once identified, could present favorable targets for novel brain stimulation treatments.
    Methods: We recently published a parcellation of the FPC based on diffusion tensor imaging data, identifying distinct medial and lateral subregions. Here, we applied this parcellation to resting-state functional magnetic resonance imaging scans obtained in 56 patients with TNRD and 56 matched healthy control subjects.
    Results: In patients, the medial FPC showed reduced connectivity to the anterior midcingulate cortex and insula. The left lateral FPC showed reduced connectivity to the right lateral orbitofrontal cortex and increased connectivity to the fusiform gyri. In addition, TNRD symptom severity correlated significantly with connectivity of the left lateral FPC subregion to a medial orbitofrontal cortex region of the classical reward network.
    Conclusions: Taken together, these findings suggest that changes in FPC subregion connectivity may underlie several dimensions of TNRD pathology, including changes in reward/positive valence, nonreward/negative valence, and cognitive control domains. Nodes of functional networks showing abnormal connectivity to the FPC could be useful in generating novel candidates for therapeutic brain stimulation in TNRD.
    MeSH term(s) Adult ; Brain Mapping ; Cerebral Cortex/physiopathology ; Depression/physiopathology ; Depressive Disorder, Major/physiopathology ; Depressive Disorder, Major/therapy ; Female ; Frontal Lobe/physiopathology ; Functional Neuroimaging ; Humans ; Magnetic Resonance Imaging/methods ; Male ; Middle Aged ; Neural Pathways/physiopathology ; Prefrontal Cortex/physiopathology
    Language English
    Publishing date 2017-12-27
    Publishing country United States
    Document type Journal Article ; Research Support, Non-U.S. Gov't
    ZDB-ID 2879089-3
    ISSN 2451-9030 ; 2451-9022
    ISSN (online) 2451-9030
    ISSN 2451-9022
    DOI 10.1016/j.bpsc.2017.12.003
    Database MEDical Literature Analysis and Retrieval System OnLINE

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  5. Article: Effect of spinal flexion on the conus medullaris: a case series using magnetic resonance imaging.

    Fettes, P D W / Leslie, K / McNabb, S / Smith, P J

    Anaesthesia

    2006  Volume 61, Issue 6, Page(s) 521–523

    Abstract: ... cephalad [3 mm caudad to 1 mm cephalad]; p = 1.0). Whilst spinal flexion may facilitate needle insertion ...

    Abstract Anatomy textbooks state that the conus medullaris moves cephalad when the vertebral column is flexed. This could confer protection against spinal cord damage during dural puncture, but has not been demonstrated in vivo. We therefore imaged the spine of 10 volunteers using magnetic resonance imaging to determine if such movement occurs with the spine in the neutral and flexed positions. The position of the conus medullaris in relation to the superior endplate of the L1 vertebra was determined. On spinal flexion, the conus medullaris moved cephalad in three subjects and caudad in three subjects, with no change in the remaining four. The median overall movement (95% CI [range]) was 0 mm (4 mm caudad to 1 mm cephalad [3 mm caudad to 1 mm cephalad]; p = 1.0). Whilst spinal flexion may facilitate needle insertion during dural puncture, it is unlikely to confer extra protection against spinal cord damage.
    MeSH term(s) Adult ; Anthropometry ; Female ; Humans ; Lumbar Vertebrae/anatomy & histology ; Magnetic Resonance Imaging ; Male ; Movement ; Spinal Cord/anatomy & histology ; Spinal Cord/physiology ; Spinal Puncture
    Language English
    Publishing date 2006-06
    Publishing country England
    Document type Journal Article
    ZDB-ID 80033-8
    ISSN 1365-2044 ; 0003-2409
    ISSN (online) 1365-2044
    ISSN 0003-2409
    DOI 10.1111/j.1365-2044.2006.04641.x
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  6. Article: Comparison of plain and hyperbaric solutions of ropivacaine for spinal anaesthesia.

    Fettes, P D W / Hocking, G / Peterson, M K / Luck, J F / Wildsmith, J A W

    British journal of anaesthesia

    2005  Volume 94, Issue 1, Page(s) 107–111

    Abstract: ... significant differences in median time to onset of sensory block at T10 (plain 10 min; hyperbaric 5 min; P<0 ... 01), median maximum extent (plain T8; hyperbaric T4; P<0.05), and median duration of sensory block ... at T10 (plain 25 min; hyperbaric 115 min; P<0.001). However, median times to complete regression ...

    Abstract Background: Preliminary work has shown that ropivacaine provides spinal anaesthesia of shorter duration than bupivacaine, and may be of particular use in the day-case setting. However, there are few data comparing the actions of plain and hyperbaric solutions of this drug.
    Methods: Forty ASA grade I-II patients undergoing elective perineal surgery under spinal anaesthesia were randomized to receive 3 ml ropivacaine 5 mg ml(-1), either in plain solution or with glucose 50 mg ml(-1). The extent and duration of sensory and motor block, pulse rate, blood pressure, and time to mobilization were recorded.
    Results: Two patients (one per group) were withdrawn because of total block failure. There were significant differences in median time to onset of sensory block at T10 (plain 10 min; hyperbaric 5 min; P<0.01), median maximum extent (plain T8; hyperbaric T4; P<0.05), and median duration of sensory block at T10 (plain 25 min; hyperbaric 115 min; P<0.001). However, median times to complete regression of both sensory (270 vs 240 min; P<0.05) and motor (180 vs 120 min; P<0.001) block were longer in the plain group. Patients therefore mobilized sooner in the hyperbaric group (218 [n=16] vs 286 min [n=17]; P<0.01). All the hyperbaric blocks were adequate for surgery, but three patients receiving plain ropivacaine required general anaesthesia.
    Conclusion: Addition of glucose 50 mg ml(-1) to ropivacaine 5 mg ml(-1) increases the speed of onset, block reliability, duration of useful block for perineal surgery, and speed of recovery. Plain solutions are less reliable for surgery above a dermatomal level of L1.
    MeSH term(s) Adult ; Aged ; Amides/administration & dosage ; Amides/chemistry ; Anesthesia Recovery Period ; Anesthesia, Spinal/methods ; Anesthetics, Local/administration & dosage ; Anesthetics, Local/chemistry ; Blood Pressure/drug effects ; Double-Blind Method ; Female ; Glucose ; Heart Rate/drug effects ; Humans ; Male ; Middle Aged ; Movement/drug effects ; Perineum/surgery ; Sensation/drug effects ; Specific Gravity
    Chemical Substances Amides ; Anesthetics, Local ; ropivacaine (7IO5LYA57N) ; Glucose (IY9XDZ35W2)
    Language English
    Publishing date 2005-01
    Publishing country England
    Document type Clinical Trial ; Journal Article ; Randomized Controlled Trial ; Research Support, Non-U.S. Gov't
    ZDB-ID 80074-0
    ISSN 1471-6771 ; 0007-0912
    ISSN (online) 1471-6771
    ISSN 0007-0912
    DOI 10.1093/bja/aei008
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  7. Article: Intermittent vs continuous administration of epidural ropivacaine with fentanyl for analgesia during labour.

    Fettes, P D W / Moore, C S / Whiteside, J B / McLeod, G A / Wildsmith, J A W

    British journal of anaesthesia

    2006  Volume 97, Issue 3, Page(s) 359–364

    Abstract: ... 95% CI 9.6-61.7%, P=0.02). Therefore the intermittent group received a lower total drug dose ... than the infusion group (P=0.02). Duration of uninterrupted analgesia (time to first rescue bolus) was longer ... in the intermittent group (P<0.02).: Conclusions: The intermittent group required fewer supplementary injections ...

    Abstract Background: Many years ago regular intermittent bolus administration of epidural local anaesthetic solution was recognized to produce more effective analgesia than continuous infusion, but only recently has the development of suitable pumps allowed the former technique's wider evaluation.
    Methods: In this randomized, double-blind trial, 40 primigravid patients had a lumbar epidural catheter inserted, and plain ropivacaine 0.2% 15-20 ml was titrated until analgesia and bilateral sensory block to T10 were produced (time zero). Patients were then given either an infusion of ropivacaine 2 mg ml(-1) with fentanyl 2 microg ml(-1) at 10 ml h(-1), or hourly boluses of 10 ml of the same solution. Pain, sensory block and motor block were measured frequently. If requested, additional 10 ml boluses of the study mixture were given for analgesia.
    Results: There were no differences between the two groups in patient characteristics, obstetric/neonatal outcome, or in sensory or motor block. A total of 12 (60%) patients in the continuous group required one or more additional boluses compared with 4 (20%) patients in the intermittent group (95% CI 9.6-61.7%, P=0.02). Therefore the intermittent group received a lower total drug dose than the infusion group (P=0.02). Duration of uninterrupted analgesia (time to first rescue bolus) was longer in the intermittent group (P<0.02).
    Conclusions: The intermittent group required fewer supplementary injections and less drug to maintain similar pain scores, sensory and motor block compared with the continuous group. This represents a more efficacious mode of analgesia.
    MeSH term(s) Adult ; Amides/administration & dosage ; Analgesia, Epidural/methods ; Analgesia, Obstetrical/methods ; Analgesics, Opioid/administration & dosage ; Anesthetics, Local/administration & dosage ; Double-Blind Method ; Drug Administration Schedule ; Female ; Fentanyl/administration & dosage ; Humans ; Infusion Pumps ; Pain Measurement ; Pregnancy ; Pregnancy Outcome
    Chemical Substances Amides ; Analgesics, Opioid ; Anesthetics, Local ; ropivacaine (7IO5LYA57N) ; Fentanyl (UF599785JZ)
    Language English
    Publishing date 2006-09
    Publishing country England
    Document type Comparative Study ; Journal Article ; Randomized Controlled Trial
    ZDB-ID 80074-0
    ISSN 1471-6771 ; 0007-0912
    ISSN (online) 1471-6771
    ISSN 0007-0912
    DOI 10.1093/bja/ael157
    Database MEDical Literature Analysis and Retrieval System OnLINE

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