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However, this observation is counterbalanced by the fact that more junior trainees performed fewer anaesthetics overall, with the rate of AAGA still considerably higher (approximately 1:150 patients) compared with experienced anaesthesia providers. One third of patients who experienced AAGA met the DSM-5 criteria for PTSD, giving a 42-fold increase in the odds for PTSD compared with non-AAGA controls. The authors estimated that approximately 1:200 (12 of 3115) patients undergoing caesarean delivery had experienced AAGA, which represents a three-fold higher rate than the self-reported rate by obstetric patients in the NAP5 study [1], and a comparable incidence to that reported by Paech et al. in 2008 [4]. Keywords: anaesthesia; awareness; general; obstetric EN anaesthesia awareness general obstetric 736 739 4 05/05/21 20210601 NES 210601 Accidental awareness during general anaesthesia (AAGA), which is approximately 10-fold more common during caesarean birth than during most other types of surgery (5th UK National Audit Project - NAP5) [1], can be a devastating event. [Extracted from the article]

Sugammadex more rapidly and reliably reverses rocuronium-induced neuromuscular block compared with neostigmine, but it is not known if subsequent patient outcomes, including nausea, vomiting and other aspects of recovery are modified. In this study, we compared the recovery characteristics of sugammadex and neostigmine/glycopyrrolate following reversal of neuromuscular block. This was a single-centre, randomised, blinded, parallel-group clinical trial in women undergoing elective day-surgical laparoscopic gynaecological surgery, with a standardised general anaesthesia regimen that included rocuronium. Neuromuscular block was reversed with either sugammadex 2 mg.kg-1 or neostigmine 40 μg.kg-1 and glycopyrrolate 400 μg. The primary outcome was the incidence of nausea and vomiting during the first six postoperative hours. Secondary outcomes included other measures of postoperative recovery such as patient symptoms and recovery scores. Three-hundred and four women were analysed by intention-to-treat (sugammadex n = 151, neostigmine n = 153), which included four major protocol violations. There was no significant difference between sugammadex and neostigmine groups in the incidence of early nausea and vomiting (49.0% vs. 51.0%, respectively; OR 0.92, 95%CI 0.59-1.45; p = 0.731). Double vision (11.5% vs. 20.0%; p = 0.044) and dry mouth (71.6% vs. 85.5%; p = 0.003) were less common after sugammadex. Sedation scores at 2 h were also lower after sugammadex (median (IQR [range]) 0 (0-3 [0-10]) vs. 2 (0-4.[0-10]); p = 0.021). Twenty-four-hour recovery scores were not significantly different between groups. Reversal with sugammadex in this patient population did not reduce postoperative nausea or vomiting compared with neostigmine/glycopyrrolate. [ABSTRACT FROM AUTHOR]

Prophylactic vasopressor administration is commonly recommended to reduce maternal hypotension during spinal anaesthesia for caesarean section. Metaraminol has undergone limited investigation in obstetric anaesthesia for this purpose, particularly in comparison with phenylephrine. In this multicentre, randomised, double-blind, non-inferiority study, we compared prophylactic phenylephrine or metaraminol infusions, started immediately after spinal anaesthesia, in 185 women who underwent elective caesarean section. Phenylephrine was initially infused at 50 μg.min-1 , and metaraminol at 250 μg.min-1 . The primary outcome was the difference in umbilical arterial pH between groups; secondary outcomes included other neonatal acid-base measures, and maternal haemodynamic changes. The mean (SD) umbilical arterial pH was 7.28 (0.06) in the phenylephrine group vs. 7.31 (0.04) in the metaraminol group (p = 0.0002). The estimated mean (95%CI) pH difference of 0.03 (0.01-0.04) was above the pre-determined lower boundary of clinical non-inferiority, and also met the criterion for superiority. Umbilical artery lactate concentration was 2.8 (1.2) mmol.l-1 in the phenylephrine group vs. 2.3 (0.7) mmol.l-1 in the metaraminol group (p = 0.0018). Apgar scores did not significantly differ between groups. There was a higher incidence of hypotension, defined as systolic arterial pressure < 90% baseline, in the phenylephrine group; there was a higher incidence of hypertension and severe hypertension (systolic arterial pressure > 110% and > 120% baseline, respectively) in the metaraminol group. There was no significant difference between groups in the incidence of nausea, vomiting or maternal bradycardia. We conclude that, when used as an infusion to prevent hypotension after spinal anaesthesia for elective caesarean section, metaraminol is at least non-inferior to phenylephrine with respect to neonatal acid-base outcomes. [ABSTRACT FROM AUTHOR]

The author discusses 2 studies on intrathecal morphine and continuous nerve block. These include one by MJ Fredrickson and TK Danesh-Clough comparing continuous lumbar plexus block with intrathecal morphine in patients of mean age 63 years and another by D. Olive et a which explores the combination of intrathecal morphine and continuous femoral nerve block in a 3-arm trial among 81 patients of mean age more than 65 years under spinal anaesthesia for elective knee arthroplasty.

A letter to the editor is presented in response to the article "Comparison of Analgesic Efficacy of Four-Quadrant Transversus Abdominis Plane (TAP) Block and Continuous Posterior TAP Analgesia With Epidurial Analgesia in Patients Undergoing Laparoscopic Colorectal Surgery: An Open-Label, Randomised, Non-Inferiority Trial" in the 2014, issue 69 of the periodical.

The benefit of combining non-opioid analgesics with neuraxial opioids for analgesia after caesarean delivery has not been clearly established. Larger doses of paracetamol or cyclooxygenase-2 inhibitors have not been evaluated. A randomised, double blind, double-dummy, parallel group placebo-controlled clinical trial was conducted among women having elective caesarean delivery under spinal anaesthesia, followed by pethidine patient-controlled epidural analgesia. Patients received placebos (group C); intravenous parecoxib 40 mg then oral celecoxib 400 mg at 12 hours (group PC); intravenous paracetamol 2 g then oral 1 g six-hourly (group PA); or these regimens combined (group PCPA). The primary outcome was 24-hour postoperative patient- controlled epidural pethidine use and the main secondary outcome was postoperative pain. One hundred and thirty-eight women were recruited but 27 subsequently met exclusion criteria, leaving 111 who were randomised, allocated and analysed by intention-to-treat (n=23, 30, 32 and 26 in groups C, PC, PA and PCPA respectively). There were no differences between groups for pethidine consumption, based on either intention-to-treat (median 365, 365, 405 and 360 mg in groups C, PC, PA and PCPA respectively, P=0.84) or per protocol analysis (17 major violations). Dynamic pain scores did not differ between groups but requirement for, and dose of, supplementary oral tramadol was least in group PCPA (incidence 23% versus 48%, 70% and 58% in groups C, PC and PA respectively, P=0.004). The addition of regular paracetamol, cyclooxygenase-2 inhibitors or both to pethidine patient-controlled epidural post-caesarean analgesia did not provide a pethidine dose-sparing effect during the first 24 hours. [ABSTRACT FROM AUTHOR]

The author reflects on the effect of limiting the dose of anaesthesia for caesarean section. He states that spinal anaesthesia for caesarian operation should last the duration of the procedure without incurring fetal and maternal adverse effects. The author says that the dose of subarachnoid local anaesthetic influences the degree and the frequency of hypotension of the patient.

The article discusses a review which summarizes the physiological and pharmacological changes that occur when an obese woman becomes pregnant. It discusses the obstetric and obstetric anaesthetic implications of moderate and severe obesity. Suggestions for the safe anaesthetic management of these women for labor and delivery are also provided.

The article examines the influence of gender and experience on intubation ability and laryngoscopic technique. The primary hypothesis was that there are differences between female and male novice intubators in intubation ability. The secondary hypothesis was that markers of intubation ability were influenced by the forces generated and laryngoscopic grip. Results showed no significant differences between novice or experienced female and make intubators in markers of their ability to intubate or in the forces generated.

The article focuses on a study which examined the extent of bacterial contamination of fentanyl solutions taken from non-sterile packaged glass fentanyl ampoules. Aspiration methods used include aspirating through a 5 µ meter (m) filter needle, aspirating through a 5 µ m filter needle after swabbing the neck of the ampoule with isopropyl alcohol, and aspirating through an antibacterial filter and 5 µ m filter needle. Study authors did not find any bacterial contamination of fentanyl solution irrespective of aspiration methods.

A super morbidly obese (230 kg, body mass index 76 kg/m2) patient presented to our service for a planned elective caesarean section for twin delivery. She subsequently underwent a non-elective caesarean section after normal working hours under combined spinal epidural anaesthesia with invasive monitoring. Complex cases such as this, especially in the obstetric setting, require thorough multidisciplinary planning, communication and expertise but can be safely and successfully performed in dedicated stand-alone centres. [ABSTRACT FROM AUTHOR]

The case of a parturient, who first presented with a partial oculomotor nerve palsy shortly after caesarean delivery while participating in a clinical trial, is presented. The anaesthesia for the caesarean delivery involved a combined spinal-epidural with intrathecal bupivacaine and postoperative epidural pethidine patient-controlled analgesia. The trial was examining the possible effects of magnesium infusions on acute and chronic pain. The partial oculomotor nerve palsy was an unusual presentation and the signs and symptoms were transient. Magnetic resonance imaging confirmed the presence of a presumed pituitary macroadenoma. Possible reasons for the timing of onset and the rapid resolution of symptoms, and the implications and management of pituitary pathology in the peripartum period, are considered. The uncomplicated course of a later caesarean delivery in the same patient, using the same anaesthesia technique, is also noted. [ABSTRACT FROM AUTHOR]

One hundred women were randomly allocated to the left lateral, Oxford or sitting position for induction of combined spinal-epidural anaesthesia for Caesarean section using 2.5 ml hyperbaric bupivacaine 0.5% and 10 μg fentanyl. Women in the left lateral were then turned to the right lateral position; women in the Oxford position were turned to the same position on their opposite side; and women in the sitting group were turned to the supine left tilt position. Women remained in these positions until ready for surgery, which was conducted in the supine position with a wedge placed under the right hip. Ephedrine requirements before re-positioning for surgery were less in the sitting position than in the other two positions: median (IQR[range]) doses for the lateral, Oxford and sitting groups were 21 (12–30[6–48]), 18 (7.5–24[6–48]) and 12 (6–21[6–42]) mg, respectively; p = 0.04. Sensory block to touch sensation at the T5 dermatomal level was most quickly achieved in the lateral position with median (IQR[range]) block onset times for the lateral, Oxford and sitting groups of 9 (6–13[4–30]), 15.5 (9–22[4–34]) and 14 (9–18[6–36]) min, respectively; p = 0.004. In the Oxford position, more epidural catheters required dosing to achieve a sensory block of T5 before surgery: the number of patients (proportion) bolused in the lateral, Oxford and sitting groups was 1 (3%), 7 (22%) and 1 (3%), respectively; p = 0.01. We did not demonstrate any advantage in using the Oxford position for combined spinal-epidural anaesthesia for elective Caesarean section. [ABSTRACT FROM AUTHOR]

We performed a randomised, crossover, single-blind trial among 168 patients, to compare the single-use SoftSeal™ and LMA Unique™ laryngeal mask airways in spontaneously breathing adults. Size-3 and -4 laryngeal mask airways, inserted by experienced anaesthetists, performed equivalently for successful first-time placement (148 (91%)vs155 (96%) for the SoftSeal™ and LMA Unique™, respectively). The SoftSeal™ was more often rated as difficult to insert (27 (17%)vs4 (3%); p < 0.001) and was more likely to show evidence of mucosal trauma after the first insertion (14 (10%)vs5 (4%); OR 1.3 (95% CI 1.3–11.3); p < 0.05). The fibreoptic view of the larynx was better through the SoftSeal™ (vocal cords not visible in 27 (17%)vs44 (27%); p < 0.05) and it more frequently provided a ventilation seal at 20 cmH2O (93 (59%)vs62 (39%); OR 2.15 (CI 1.44–3.21); p < 0.001). In contrast to the LMA Unique™, its cuff pressure did not increase during nitrous oxide anaesthesia (median (IQR[range]) decrease 3 (− 20–23[-40–94]) cmH2Ovsincrease of 16 (−2–39[−54–112]) cmH2O; p < 0.01). Both devices were equivalent for the success of first-time insertion and performed satisfactorily clinically. There were some performance differences, but either appears suitable for airway management in spontaneously breathing patients. [ABSTRACT FROM AUTHOR]

Summary Twenty-four gynaecological patients receiving postoperative patient-controlled analgesia were enrolled in an open cross-over pilot study evaluating two new formulations of nasal fentanyl spray. The primary outcome was the bioavailability of nasal fentanyl in comparison with intravenous fentanyl. This manuscript describes the clinical outcomes of quality of postoperative analgesia and patient acceptability. There were 21 complete data sets for both sequences of the cross-over design. In randomised order, patients received approximately 50 μg of fentanyl in a single dose by intranasal and intravenous administration, but separated by at least 2 h. Analgesia was of rapid onset (within 5 min) and similar quality. There was no significant difference in side-effects. Four patients experienced mild nasal stinging and although 10 (42%) preferred intravenous administration, seven (29%) preferred intranasal and six (25%) had no preference. We conclude that these formulations of fentanyl, delivered as nasal spray, have potential clinical utility. [ABSTRACT FROM AUTHOR]

The article reflects on whether fasted pregnant women are at significantly increased risk of pulmonary aspiration and whether the use of a supraglottic airway device is appropriate. The application of cricoid pressure did not prevent maternal aspiration and death in 9 of 11 cases according to an observational study conducted in Africa. It questions whether pregnant women should mandatorily receive a rapid sequence induction with cricoid pressure.

The authors discuss the auditing of hand-written anesthetic records within the medical records of patients in a tertiary maternity unit in Australia that performs around 2,000 cesarean deliveries annually. They mention the use of the anesthetic department's audit database to identify cesarean deliveries conducted under spinal, epidural or combined spinal and epidural anesthesia in 2012. The recording of the nature, timing, and location of central neuraxial block for cesarean sections is cited.

A letter to the editor about the EpiSure loss-of-resistance syringe is presented.

Purpose of the study: To investigate the transfer of rac-tramadol and its rac-O-desmethyl metabolite into transitional milk, to estimate the absolute and relative infant doses via milk, and to assess unwanted effects in the breastfed infant. Methods: Tramadol HCl (100 mg six hourly) was administered to 75 breastfeeding mothers for postoperative analgesia on days 2–4 after caesarian section. Three samples of transitional milk and one of plasma were collected over 6–14 h following the 4th dose. Tramadol and O-desmethyltramadol were measured by high performance liquid chromatography. Milk/plasma ratio (M/P) was calculated, and absolute infant dose and relative infant dose were calculated by standard methods. The behavioral characteristics of the exposed breastfed infants and a matched control group of infants not exposed to tramadol were also studied. Results: Mean (95% CI) M/P was 2.2 (2.0–2.4) for tramadol and 2.8 (2.5–3.1) for O-desmethyltramadol. Average concentrations in milk across a 6 h dose interval at steady-state were 748 (681–815) mcg l−1 for tramadol and 203 (188–217) mcg l−1for O-desmethyltramadol. Estimated absolute and relative infant doses were 112 (102–122) mcg kg−1 day−1 and 30 (28–32) mcg kg−1 day−1, and 2.24 (2.04–2.44)% and 0.64 (0.59–0.69)% for tramadol and O-desmethyltramadol respectively. The exposed infants and control breastfed infants had similar characteristics, including Apgar scores at birth and Neurologic and Adaptive Capacity Scores (NACS) on days 3–4 after birth. Conclusions: The absolute infant doses for tramadol and its active metabolite combined were around 14% of the child therapeutic dose for tramadol. The combined relative infant dose of 2.88% of the weight-adjusted maternal dose was also low. The similarity of NACS in exposed infants and controls suggests that there were no clinically significant effects on infant well-being. We conclude that short-term maternal use of tramadol during establishment of lactation is safe for the breastfed infant. [ABSTRACT FROM AUTHOR]

Drug abuse is a significant social problem that can lead to serious obstetric complications, some of which may be confused with pregnancy-related disease states. Substance abuse poses a number of challenges with respect to the management of pain and the conduct of anaesthesia in the peripartum period. This review was based on information from a literature search of epidemiological, research and review papers on substance abuse during pregnancy, obtained for the purpose of preparing a background paper for the Ministerial Council on Drug Strategy, Commonwealth Government of Australia. Given that almost 80% of substance-abusing parturients require anaesthetic services in the perinatal period, early antenatal referral for anaesthetic review is recommended. To optimise the care of these vulnerable patients, obstetricians, general practitioners and midwives should attempt to identify substance-abusing parturients and refer them to an anaesthetist. A careful anaesthetic evaluation with non-judgemental questioning is essential, with management tailored to individual patient needs and the urgency of obstetric intervention for vaginal delivery or caesarean section. Opioid-dependent women, in particular, benefit from antenatal pain management planning. Patients recovering from drug addiction should also have a well-documented analgesic strategy. A multidisciplinary approach will involve obstetricians, anaesthetists and staff of the Drug and Alcohol Service. In acute admissions of women by whom antenatal care was not accessed, a high index of suspicion for illicit drug use should arise. Because illicit substance use is so prevalent, if untoward reactions occur during an otherwise uneventful anaesthetic, the possibility of drug abuse should be considered. [ABSTRACT FROM AUTHOR]

In vitro morphine does not reduce cilia beat frequency, a key factor determining bronchial mucus transport velocity. There are no reports about the effect of remifentanil on bronchial mucus transport. We compared the bronchial mucus transport velocity in patients having total intravenous anaesthesia with either propofol and morphine, or propofol and remifentanil. Twenty patients scheduled for elective surgery were randomly allocated to the two groups. Fifteen minutes after insertion of the laryngeal mask airway, bronchial mucus transport velocity was assessed by fibreoptic observation of the movement of methylene blue dye applied to the right main bronchus. Compared with morphine, bronchial mucus transport velocity was significantly reduced in patients receiving remifentanil (morphine mean (SD) 9.2 (5.8) vs remifentanil 4.2 (3.0) mm.min−1, p = 0.028). Anaesthesia with remifentanil may lead to significantly impaired bronchociliary clearance in comparison to morphine. This could have clinical implications, in particular in patients at risk. [ABSTRACT FROM AUTHOR]

We conducted a prospective observational study among a cohort of 40 term parturients undergoing spinal anaesthesia for elective Caesarean section, to determine the concentration ofβ-trace protein in cerebrospinal fluid (CSF) and serum. Serum and CSF samples, taken at the time of dural puncture, were assayed by nephelometry. The mean serumβ-trace protein concentration was 0.39 mg.l−1 and the mean CSF concentration was 27.9 mg.l−1, giving a mean ratio of CSF to serum concentration of 76. This ratio is higher than that published for non-pregnant females and for males because of both a higher mean CSF and a lower mean serumβ-trace protein concentration. The concentration correlated positively with both serum creatinine and gestational age. If these concentrations are used to estimate the normal range, we propose that the nephelometric measurement ofβ-trace protein might prove a useful diagnostic test for cerebrospinal fluid-cutaneous fistula in parturients. [ABSTRACT FROM AUTHOR]

We conducted a prospective, randomised, double-blind trial to study the effect of Synacthen Depot in 18 parturients with postdural puncture headache following deliberate or accidental dural puncture. Women were randomly allocated to receive either Synacthen Depot 1 mg (1 ml) or 0.9% saline 1 ml intramuscularly. Using a 10-cm visual analogue scale, severity of headache was measured before and at intervals until 48 h after injection. There was no difference in the severity of headache or requirement for epidural blood patch. We conclude that there is no advantage to the use of Synacthen Depot 1 mg for the treatment of postdural puncture headache. [ABSTRACT FROM AUTHOR]

We conducted a prospective, randomised, double-blind trial to study the effect of Synacthen Depot® in 18 parturients with postdural puncture headache following deliberate or accidental dural puncture. Women were randomly allocated to receive either Synacthen Depot 1 mg (1 ml) or 0.9% saline 1 ml intramuscularly. Using a 10-cm visual analogue scale, severity of headache was measured before and at intervals until 48 h after injection. There was no difference in the severity of headache or requirement for epidural blood patch. We conclude that there is no advantage to the use of Synacthen Depot 1 mg for the treatment of postdural puncture headache. [ABSTRACT FROM AUTHOR]

The article discusses the case of a pregnant patient who developed diabetic ketoacidosis (DKA) due to the malfunction of her subcutaneous insulin pump. Topics discussed include clinical presentation of the patient, the negative effects of increased insulin resistance, and the pathophysiology of DKA during pregnancy.

Background: Previous animal and clinical studies showed that nitrous oxide may produce long-term analgesia. The aim of this study was to evaluate the effect of nitrous oxide in preventing chronic postsurgical pain. We also explored whether methylenetetrahydrofolate reductase gene polymorphisms (1298A>C, 667C>T) would enhance nitrous oxide analgesia.Methods: We conducted a telephone interview at 12 months after surgery on 2924 (41.1%) patients enrolled in the Evaluation of Nitrous Oxide in the Gas Mixture for Anaesthesia-II trial. Pain at the wound site was recorded using the modified brief pain inventory and the neuropathic pain questionnaire. General health status was measured using the EQ-5D questionnaire. Genotyping was performed in a subset of 674 Asian patients in Hong Kong.Results: At 12 months after surgery, 356 (12.2%) patients reported chronic postsurgical pain at the wound site and 112 (3.8%) patients had severe pain and required regular analgesic interventions. Nitrous oxide did not affect the rate of chronic postsurgical pain (11.8% nitrous oxide group; 12.5% no nitrous oxide group), relative risk (95% confidence intervals): 0.94 (0.75-1.17), P=0.57. However, in a planned subgroup analysis, nitrous oxide reduced the risk of chronic postsurgical pain in Asian patients, relative risk (95% confidence intervals): 0.70 (0.50-0.98), P=0.031. Patients who were homozygous for either gene polymorphism and who received nitrous oxide during surgery were less likely to report chronic postsurgical pain.Conclusions: Nitrous oxide administration had no impact on chronic postsurgical pain, but benefits may still be possible in Asian patients and patients with variants in methylenetetrahydrofolate reductase gene.Clinical Trial Registration: NCT00430989. [ABSTRACT FROM AUTHOR]

Paracetamol and non-steroidal anti-inflammatory drugs are often administered for postoperative analgesia. Dilatation and curettage, with or without hysteroscopy, is a common day-stay procedure that is associated with pain that is partly mediated by prostaglandins. This study aimed to investigate the analgesic efficacy of adjunctive paracetamol and parecoxib in this setting. A randomised, blinded, placebo-controlled, single-centre trial was conducted among 240 women undergoing dilatation and curettage. Patients were randomised intraoperatively into one of four groups, to receive either intravenous paracetamol 2 g, intravenous parecoxib 40 mg, both in combination, or placebos, post-induction and with intravenous fentanyl. The primary endpoints were pain score one hour postoperatively and the Overall Benefit of Analgesia Score. There were no statistically significant differences in primary outcomes across groups. The area under the curve for pain scores to two hours postoperatively was significantly lower in the group receiving paracetamol (P=0.018) and the need for rescue analgesia with tramadol was less in the combination group (P=0.02). There were no significant differences in patient satisfaction or recovery. We conclude that paracetamol or parecoxib does not produce a clinically important reduction in pain in this setting. Women having uterine curettage and receiving intravenous fentanyl do not appear to benefit from administration of these non-opioid analgesics. [ABSTRACT FROM AUTHOR]

The benefit of combining non-opioid analgesics with neuraxial opioids for analgesia after caesarean delivery has not been clearly established. Larger doses of paracetamol or cyclooxygenase-2 inhibitors have not been evaluated. A randomised, double blind, double-dummy, parallel group placebo-controlled clinical trial was conducted among women having elective caesarean delivery under spinal anaesthesia, followed by pethidine patient-controlled epidural analgesia. Patients received placebos (group C); intravenous parecoxib 40 mg then oral celecoxib 400 mg at 12 hours (group PC); intravenous paracetamol 2 g then oral 1 g six-hourly (group PA); or these regimens combined (group PCPA). The primary outcome was 24-hour postoperative patient-controlled epidural pethidine use and the main secondary outcome was postoperative pain. One hundred and thirty-eight women were recruited but 27 subsequently met exclusion criteria, leaving 111 who were randomised, allocated and analysed by intention-to-treat (n=23, 30, 32 and 26 in groups C, PC, PA and PCPA respectively). There were no differences between groups for pethidine consumption, based on either intention-to-treat (median 365, 365, 405 and 360 mg in groups C, PC, PA and PCPA respectively, P=0.84) or per protocol analysis (17 major violations). Dynamic pain scores did not differ between groups but requirement for, and dose of, supplementary oral tramadol was least in group PCPA (incidence 23% versus 48%, 70% and 58% in groups C, PC and PA respectively, P=0.004). The addition of regular paracetamol, cyclooxygenase-2 inhibitors or both to pethidine patient-controlled epidural post-caesarean analgesia did not provide a pethidine dose-sparing effect during the first 24 hours. [ABSTRACT FROM AUTHOR]

Paracetamol and non-steroidal anti-inflammatory drugs are often administered for postoperative analgesia. Dilatation and curettage, with or without hysteroscopy, is a common day-stay procedure that is associated with pain that is partly mediated by prostaglandins. This study aimed to investigate the analgesic efficacy of adjunctive paracetamol and parecoxib in this setting. A randomised, blinded, placebo-controlled, single-centre trial was conducted among 240 women undergoing dilatation and curettage. Patients were randomised intraoperatively into one of four groups, to receive either intravenous paracetamol 2 g, intravenous parecoxib 40 mg, both in combination, or placebos, post-induction and with intravenous fentanyl. The primary endpoints were pain score one hour postoperatively and the Overall Benefit of Analgesia Score. There were no statistically significant differences in primary outcomes across groups. The area under the curve for pain scores to two hours postoperatively was significantly lower in the group receiving paracetamol (P=0.018) and the need for rescue analgesia with tramadol was less in the combination group (P=0.02). There were no significant differences in patient satisfaction or recovery. We conclude that paracetamol or parecoxib does not produce a clinically important reduction in pain in this setting. Women having uterine curettage and receiving intravenous fentanyl do not appear to benefit from administration of these non-opioid analgesics. [ABSTRACT FROM AUTHOR]

The POISE Trial was a randomised, placebo-controlled, double-blind study of the effectiveness of perioperative beta-blockade in preventing cardiac events including death in 8351 patients. Our hypothesis was that knowledge of the results of the POISE Trial would either increase or decrease the use of effective perioperative beta-blockade, depending on the result. Patients presenting for non-cardiac surgery and at risk of perioperative cardiac events were recruited in two cohorts before and after the release of the POISE Trial results. Effective perioperative beta-blockade was defined as heart rate <65 beats per minute for at least 80% of the perioperative period in patients prescribed beta-blockers. Effective perioperative beta-blockade was achieved in 22 (11.5%) of 191 patients prescribed perioperative beta-blockade in the first cohort (n=392) and seven (6%) of 118 patients in the second cohort (n=241) (P=0.10). Effective heart rate control was achieved in 29 (9%) patients prescribed perioperative beta-blockers compared with 10 (3%) patients not prescribed perioperative beta-blockers (P=0.001). The rate of implementation of effective beta-blockade was low before POISE and this did not change significantly after publication. Our finding does not provide reliable evidence of a change in practice as a result of the POISE Trial. [ABSTRACT FROM AUTHOR]

The article discusses a study of the management and effectiveness of beta-blockers in preventing perioperative cardiac events in high-risk patients before and after the release of the POISE Trial results in 2008. The researchers examined the incentives and barriers to initiation of perioperative beta-blockade (BB) by anesthetists. They found that the rate of implementation of effective perioperative BB was low before and after publication of the results.

Purpose of the study: To evaluate the acceptability of a disposable patient-controlled intravenous analgesia (PCIA) device (Go Medical Industries, Subiaco, Western Australia) by questionnaire. Methods: Institution ethical approval was obtained. Twenty female patients requiring post operative intravenous analgesia for open abdominal surgery were prospectively recruited. Fifty members of the nursing staff and 15 anaesthesia personnel who were familiar with the device were also asked to complete a questionnaire. Data were entered onto a spreadsheet (Microsoft Excel 2002) and the findings analysed by an independent biostatistician. Results: Completed questionnaires were received from 20 patients (response rate 100%); 11 anaesthetists (73%) and 41 nurses (82%). Satisfaction with the device was high, with 50% of medical staff having a satisfaction score of 80 or more and 50% of patients and nursing staff a satisfaction score of 90 or more. Patients gave median scores of 10 (0–10 scale) for “ease of use” and “willingness to use again.” Features most liked were portability and ease of use (reported by 73% and 46% of anaesthetists and 44% and 27% of nurses). Anaesthetists most disliked equipment failure and lack of tamper proofing (55% and 36% respectively) and nurses lack of reliability, slow filling and difficulty assembling (all 12%). Conclusions: The Go Medical PCIA device provides a lightweight portable option for post operative patient controlled analgesia. It is simple to use, is associated with high staff and patient satisfaction, but has some limitations. [ABSTRACT FROM AUTHOR]

There is no high-level evidence supporting an optimal top-up solution to convert labour epidural analgesia to surgical anaesthesia for Caesarean section. The aim of this meta-analysis was to identify the best epidural solutions for emergency Caesarean section anaesthesia, with respect to rapid onset and low supplementation of intraoperative block. Eleven randomized controlled trials, involving 779 parturients, were identified for inclusion after a systematic literature search and risk of bias assessment. ‘Top-up’ boluses were classified into three groups: 0.5% bupivacaine or levobupivacaine (Bup/Levo); lidocaine and epinephrine, with or without fentanyl (LE±F); and 0.75% ropivacaine (Ropi). Pooled analysis using the fixed-effects method was used to calculate the mean difference (MD) for continuous outcomes and risk ratio (RR) for dichotomous outcomes. Lidocaine and epinephrine, with or without fentanyl, resulted in a significantly faster onset of sensory block [MD −4.51 min, 95% confidence interval (CI) −5.89 to −3.13 min, P<0.00001]. Bup/Levo was associated with a significantly increased risk of intraoperative supplementation compared with the other groups (RR 2.03; 95% CI 1.22–3.39; P=0.007), especially compared with Ropi (RR 3.24, 95% CI 1.26–8.33, P=0.01). Adding fentanyl to a local anaesthetic resulted in a significantly faster onset but did not affect the need for intraoperative supplementation. Bupivacaine or levobupivacaine 0.5% was the least effective solution. If the speed of onset is important, then a lidocaine and epinephrine solution, with or without fentanyl, appears optimal. If the quality of epidural block is paramount, then 0.75% ropivacaine is suggested. [ABSTRACT FROM PUBLISHER]

Obesity is increasing in the population as a whole, and especially in the obstetric population, among whom pregnancy-induced physiological changes impact on those already present due to obesity. In particular, changes in the cardiovascular and respiratory systems during pregnancy further alter the physiological effects and comorbidities of obesity. Obese pregnant women are at increased risk of diabetes, hypertensive disorders of pregnancy, ischaemic heart disease, congenital malformations, operative delivery postpartum infection and thromboembolism. Regional analgesia and anaesthesia is usually preferred but may be challenging. Obese pregnant women appear to have increased morbidity and mortality associated with caesarean delivery and general anaesthesia for caesarean delivery in particular, and more anaesthesia-related complications. This article summarises the physiological and pharmacological implications of obesity and pregnancy and describes the issues surrounding the management of these women for labour and delivery. [ABSTRACT FROM AUTHOR]

The article describes the establishment and enforcement of an obstetric cell salvage service in an obstetric hospital in Western Australia which has no previous experience with the technique. A quality assurance process is implemented before the actual cell salvage implementation. As part of the process, several hematological tests are performed on the salvaged blood. Some of the hematological tests performed are alpha fetoprotein, hematocrit and free plasma hemoglobin tests.

At therapeutic concentrations, parecoxib selectively inhibits the cyclo-oxygenase-2 enzyme. We investigated the impact of a single preoperative dose of parecoxib on pain relief following minor gynaecological surgery. Ninety women undergoing uterine dilatation and curettage, with or without hysteroscopy, were randomised to receive either 40 mg of parecoxib intravenously or a saline placebo prior to induction of standardised general anaesthesia. Exclusion criteria included a preoperative history of renal dysfunction or hypertension and the preoperative use of anti-inflammatory or opioid medication. The primary endpoint was the pain score during recovery. There was no difference in global pain scores or area under the curve for pain scores in the recovery area. Pain scores with coughing one hour after surgery were low in both groups but significantly lower after parecoxib (median 2 [interquartile range 0 to 4] parecoxib group vs. 2 [interquartile range 0 to 6] placebo group, P = 0.037). The 24 hour Quality of Recovery score did not differ significantly between groups but the parecoxib group was less likely to experience headache at 24 hours postoperatively (12 vs. 38%, P = 0.007) and reported complete satisfaction more frequently (78 vs. 57%, P = 0.042). The preoperative administration of parecoxib was associated with a significant but small decrease in dynamic pain scores one hour postoperatively. Women who received preoperative parecoxib had a lower incidence of postoperative headache and higher satisfaction. [ABSTRACT FROM AUTHOR]

The article discusses a study on the effectiveness of parecoxib versus placebo for pain management after minor day stay gynaecological procedures at King Edward Memorial Hospital for Women in Perth, Western Australia. There was a decreased dynamic pain scores in patients after the preoperative administration of intravenous parecoxib. They reported a reduction in postoperative headache. Also noted is the concern about the cardiovascular effects of selective cyclo-oxygenase-2 (COX-2) inhibitors.

Female anaesthetists in early training commonly question whether their strength is adequate for tracheal intubation. This study investigated the influence of gender and experience on intubation ability and laryngoscopic technique. A manikin model and purpose-designed force-transducing laryngoscope was used to test three cohorts at different levels of experience (novice, intermediate and experienced males and females, n = 65) for the axial force and torque exerted, best laryngoscopic view obtained, success with and time for intubation and laryngoscopic technique. There were no significant differences between novice or experienced female and male intubators in markers of their ability to intubate or in the forces generated. For novice females compared with novice males, mean success rate was 90% (80.2 to 99.9) versus 97% (91.1 to 100, P = 0.29); and mean time to intubate 24 seconds (19 to 29 seconds) versus 18 seconds (14 to 21 seconds, P = 0.057). With experience, the forces generated during intubation reduced and ability improved. Proximal laryngoscope grips (close to the blade) generated lower forces than distal grips. Female and male intubators did not differ in ability to intubate or in the forces they exerted during direct laryngoscopy. [ABSTRACT FROM AUTHOR]

Iatrogenic meningitis is a rare complication of spinal anaesthesia. It is mandatory to use a technique which minimises the risk of introducing bacteria into the subarachnoid space. Currently available fentanyl ampoules require a careful drawing-up technique, as the outside of the ampoule is not sterile and there is potential to contaminate the contents in the drawing-up process. We designed a pilot laboratory study to determine the extent of bacterial contamination of fentanyl solutions drawn up from non-sterile packaged glass fentanyl ampoules using three different methods: aspirating through a 5 microm filter needle only, aspirating through a 5 microm filter needle after swabbing the neck of the ampoule with isopropyl alcohol and aspirating through an antibacterial filter in addition to the 5 microm filter needle. Ten anaesthetists used each method once, in randomised order to draw up solution from three different fentanyl ampoules. Samples underwent bacterial culture in blood agar and enrichment broth for 48 hours. No significant growth was seen in any sample. This pilot study did not identify any bacterial contamination of fentanyl solution irrespective of which of the three methods for aspiration was used. [ABSTRACT FROM AUTHOR]

As the number of women giving birth by caesarean increases throughout most of the developed world, so too is research into postoperative pain relief for these women. Like most other post-surgical populations, the new mother needs effective pain relief so that she can mobilise early but she also has the added responsibility of needing to care for her newborn baby. There is no 'gold standard' for post-caesarean pain management; the number of options is large and the choice of method is at least partly determined by drug availability, regional and individual preferences, resource limitations and financial considerations. Most methods rely on opioids, supplemented with anti-inflammatory analgesics, nerve blocks or other adjunctive techniques. The aim of this review is to detail commonly used opioid-based methods and to review the evidence supporting non-opioid methods, when incorporated into a multimodal approach to post-caesarean pain management. Areas of promising research are also discussed. [ABSTRACT FROM AUTHOR]

The article reviews the commonly utilized opioid-based methods, incorporated into a multimodal approach, for post-cesarean pain management. Patient preferences and expectations, surgical difficulty and duration, and preference and experience of anaesthetist are said to influence the choice of analgesic regimen. The post-caesarian pain management approaches include neuraxial techniques and adjuncts, intrathecal, oral and epidural opioids, and nonsteroidal anti-inflammatory drugs.

Our research hypothesis was that single lung ventilation during thoracic surgery in the lateral position increases the blood concentration of propofol during target-controlled infusion. Thirty adult patients in two tertiary referral hospitals undergoing open-chest surgery were studied. Anaesthesia was induced and maintained with propofol using a Diprifusor (Graseby 3500) computer-controlled pump set to deliver a blood concentration of 4 tg.ml(-1). Blood samples were taken with the patient positioned in (1) the supine position 20 minutes after induction (supine); (2) the lateral position just prior to one-lung ventilation (lateral); (3) the lateral position five minutes after commencing one-lung ventilation (OLV5) and (4) the lateral position 20 minutes after commencing one-lung ventilation (OLV20). Propofol concentrations were determined by high performance liquid chromatography. The target-controlled infusion target level was maintained at 4 microg.ml(-1) during the study period for all cases. The mean (SD) propofol blood concentration (microg.ml(-1)) at each stage was 5.5 (1.5) supine, 5.3 (1.1) lateral, 5.3 (1.2) OLV5 and 5.1 (1.2) OLV20. Repeated measures ANOVA showed an F value 1.9, lambda 5.5 and P value 0.15. Post hoc analysis did not identify a significant difference between the sample times. During target-controlled infusion of propofol, mean blood propofol concentrations did not change significantly from those obtained with the patient supine after up to 50 minutes in the lateral position during thoracic surgery, or 20 minutes after commencing one-lung ventilation. [ABSTRACT FROM AUTHOR]

The number of fluctuations of skin conductance per second correlates with postoperative pain. The aim of this prospective study was to test the cut-off value for the number of fluctuations of skin conductance per second obtained from a previous study. Seventy-five patients were asked to quantify their level of pain on a numeric rating scale (0–10) in the recovery room. The number of fluctuations of skin conductance per second was recorded simultaneously. The number of fluctuations of skin conductance per second was different between patients with no (0.07), mild (0.16), moderate (0.28) and severe pain (0.33); p < 0.001. The tested cut-off value for the number of fluctuations of skin conductance per second (0.1) distinguished a numeric rating scale ≤ 3 from > 3 with 88.5% sensitivity and 67.7% specificity. The number of fluctuations of skin conductance per second may be a useful means of assessing postoperative pain. [ABSTRACT FROM AUTHOR]