Search

This systematic review and network meta-analysis (NMA) compared postoperative analgesic efficacy of transversus abdominis plane (TAP) blocks with that of wound infiltration for Cesarean delivery (CD) without long-acting neuraxial opioid administration. We sought randomized-controlled trials comparing TAP vs wound infiltration, and inactive control vs either TAP or wound infiltration. Wound infiltration included single-dose infiltration (WI), or continuous infusion via a catheter (WC). The primary outcome was 24 hr opioid consumption. Secondary outcomes included 12 and 24 hr pain scores (resting and movement), time to first analgesia request, incidence of postoperative nausea and vomiting (PONV), maternal sedation, and pruritus. We performed a NMA incorporating both direct and indirect comparisons and reported standardized mean differences and odds ratios with 95% confidence intervals for continuous and dichotomous outcomes. Forty-two studies were included, comprising 2,906 participants. Transversus abdominis plane blocks and WC were associated with significantly lower 24 hr opioid consumption than inactive controls, but there were no significant differences between WI and inactive controls. There was no statistically significant difference in 24 hr opioid consumption between TAP blocks and WC or WI techniques. The network ranking of treatments was TAP block, followed by WC or WI. No significant differences were shown between TAP, WC, and WI groups for 24 hr pain scores, time to first analgesia, PONV, sedation, and pruritus. Quality of evidence was moderate for most of the outcomes assessed. In the absence of long-acting neuraxial opioid after CD, single-dose TAP blocks and WC are effective opioid-sparing strategies.

Clinical identification of lumbar spinous processes is inaccurate in most patients. The purpose of this study was to determine the number of patients required to train anesthesiologists in the use of ultrasound imaging to accurately identify the lumbar spinous processes.In this pilot study, two anesthesiologists studied patients scheduled for a diagnostic computed tomography (CT) scan, including the lumbar spine. Before the CT scan, the anesthesiologist completed a systematic ultrasound scan of the lumbar spine and placed a radio-opaque marker at a designated level. The actual level was determined by a radiologist after reviewing the CT scans. The primary outcome was the number of procedures each anesthesiologist needed (by cumulative sum analysis) to be able to identify the designated spinous process 90% of the time. Secondary outcomes included the overall success rate, the magnitude of the failures (number of segments from the designated spinous process), and the incidence of spinal anomalies and their effect on reliability.We studied 74 patients. One anesthesiologist required 36 patients to meet reliability criteria, whereas the other required 22 patients. The overall accuracy rate was 68%. There were only two patients where the marker was placed more than one segment from the designated spinous process. The incidence of lumbar spine anomalies was 6.8% (n = 5), and 80% (n = 4) of these were associated with inaccurate marker placement.It is possible to use ultrasound scanning to accurately identify the lumbar spinous processes in unselected patients. This result suggests that, with appropriate training, this tool can be used to enhance the accuracy of needle placement during neuraxial techniques.

Purpose Modern neuraxial labour analgesia reflects a shift in obstetrical anesthesia thinking – away from a simple focus on pain relief towards a focus on the overall quality of analgesia. However, advances in the methods used to measure outcomes have not kept pace with clinical progress, and these approaches must evolve to facilitate meaningful assessment of the advances provided towards the quality of analgesia. Developing a tool to measure the quality of neuraxial labour analgesia that research has achieved is best guided by women’s perspectives. As the initial step in developing an instrument to quantitatively measure quality neuraxial labour analgesia, this qualitative descriptive study explored childbearing women’s experiences and perspectives regarding this subject.

Inadvertent epidural needle punctures represent the leading cause of severe postdural puncture headache (PDPH) in parturients. Use of small gauge (G) epidural needles for continuous analgesia has received little attention despite possible important reductions in PDPH. We report the first study to examine the feasibility of using small G Tuohy needles and 23 G catheters for labour analgesia.Healthy parturientsor= 6 cm dilated were recruited. Epidural analgesia was established using a 19 G Tuohy epidural needle, a 23 G single port 40 cm catheter and bupivacaine 0.08% with fentanyl 2 microg x mL(-1) (15-20 mL). Breakthrough pain was treated by protocol. There was no formal in-training period for anesthesiologists. The primary outcome was the combined failure rate for initiation (failed needle/catheter placement or failed blockor= 30 min of drug administration). Secondary out-comes included late block failure (30 min), recognized dural puncture, PDPH, patient assessment of analgesia within 24 hr of delivery, complications and anesthesiologist satisfaction.Twenty-seven parturients were recruited. Successful blocks were initiated and maintained in 24/27 who rated overall analgesia from good to excellent (19/24 very good to excellent). Three block failures occurred at the initiation phase only (two unilateral, one absent). There was no evidence of catheter kinking after placement. One patient developed PDPH after unrecognized dural puncture which was self-treated with acetaminophen for four days, followed by complete symptom resolution.It is feasible to provide high quality labour analgesia using small G epidural needles and catheters. The effect of small G epidural needles on PDPH warrants future study.

To present a case of respiratory arrest following the use of intrathecal sufentanil and bupivacaine for combined spinal-epidural anaesthesia in a healthy labouring parturient.A 20-yr-old term parturient received 10 micrograms sufentanil and 2.5 mg bupivacaine intrathecally as part of a combined spinal-epidural technique for labour analgesia. She had received no previous analgesics. Twenty-three minutes after the intrathecal injection she became unresponsive and suffered a respiratory arrest. Resuscitation included manual bag/mask ventilation with oxygen and intravenous naloxone.Respiratory arrest is a rare but potentially life-threatening complication associated with the use of intrathecal opioids for labour analgesia. Vigilance in post-procedure patient monitoring is imperative.

The purpose of this retrospective review was to highlight clinical issues relating to anesthetic management in children who present with Gaucher disease-specific features that may impact on anesthetic management and surgical outcome. Previous reports have dealt primarily with neuronopathic forms where neurological dysfunction determined the mode of anesthesia. To date, no series of routine surgeries in pediatric patients with non-neuronopathic Gaucher disease has been published. All surgeries performed in children with Gaucher disease in our institution during the period 1993-2003 were retrospectively analyzed. There were 31 procedures under anesthesia in 15 pediatric patients. Twenty-seven of these (87%) involved either insertion or removal of a central venous catheter. There was no correlation between disease severity and the need for blood transfusion postoperatively [required in only eight cases (25.8%), including a total hip replacement]. No difficult intubations or other airway problems were recorded. Positioning of two patients, because of gibbus and prior to hip replacement, respectively, required special attention. We record our experience in surgeries in children with mild, non-neuronopathic type I and severe neuronopathic type III Gaucher disease, who had relatively short surgeries under general anesthesia. Attention to hematological parameters in particular can minimize postoperative bleeding, the most serious complication.

Question In infants born before term (26–36 weeks of gestation) and infants born at term (≥37 weeks of gestation), does the Apgar score, at five minutes of age, predict 28-day neonatal death?

A prospective, randomized, double-blind study was performed to compare the analgesic efficacy and side effects of epidural fentanyl, 25 micrograms vs 50 micrograms, when used to supplement epidural anaesthesia for elective Caesarean section. Fifty ASA I and II patients were randomized into two groups: Group I (n = 24) received 25 micrograms and Group II (n = 26) received 50 micrograms of epidural fentanyl after the epidural test dose. No differences between the two groups were found on any measures of intraoperative pain, nausea, drowsiness, respiratory depression, hypotension, pruritus and neonatal outcome. The low levels of pain experienced by patients indicates that doses higher than 50 micrograms of epidural fentanyl are usually unnecessary for optimal analgesia.

The purpose of this study was to compare maternal blood loss, as reflected by the perioperative changes in haemoglobin (Hgb), the incidence of severe bleeding (estimated blood loss >1000 ml) at operation, and the need for blood transfusion, between patients who had classical caesarean section (CCS) and lower segment caesarean section (LSCS) at 34 weeks gestation or less. The data from 31 women delivered by CSS between 25 and 34 weeks gestation were compared, in a retrospective case-control fashion, to another 31 women delivered by LSCS. Patients were matched for gestational age at delivery, the type of anaesthesia, and the prior use of tocolytic therapy. Excluded from the study were patients who had an antepartum haemorrhage or placenta praevia. There was a significantly greater reduction in maternal Hgb and an higher incidence of severe bleeding in the CSS group compared to the LSCS group (P

Forty healthy parturients at term, undergoing elective Caesarean section, were divided into two groups to receive supplemental oxygen by either simple facemask (Group FM, 8 L.min-1) or nasal prongs (Group NP, 4 L.min-1) during the procedure. Anaesthesia was provided by epidural block to equivalent dermatomal levels in all patients. Maternal oxygen saturation was measured continuously with pulse oximetry and supplemental oxygen was provided to the mother after administration of the epidural test dose and continued until the end of the procedure. Following delivery of the infant and concurrent with Apgar scoring, the umbilical cord was double-clamped and arterial and venous samples were drawn. The pH, partial pressures of O2 and CO2 and O2 saturations were measured. There was no difference in the clinical condition of the neonates, as assessed by Apgar scores, or in the acid-base and oxygenation status, as assessed by blood gas analyses between the two groups. Mean umbilical vein oxygen saturation, a measure of fetal oxygen delivery, was 46 +/- 18% (95% confidence interval 39% to 54%) for Group NP and 54 +/- 17% (95% confidence interval 46% to 62%) for Group FM, again not different. We conclude that when the clinical condition, acid-base and oxygenation status of neonates, delivered by elective Caesarean section to healthy, low-risk parturients with normal placental function under epidural anaesthesia, are evaluated, it makes no difference whether the mothers received supplemental oxygen by nasal prongs or simple facemask.

Introduction: Aortic stenosis (AS) in young women is usually the result of a stenotic bicuspid aortic valve, which is the most common cardiac congenital anomaly (2-3% of the population). Severe AS carries a high risk of fetal and maternal morbidity and mortality and requires special attention. The anesthetic management of the parturient with AS has been discussed in several case reports. We presented our experience in peripartum anesthetic management of patients with moderate and severe AS. Methods: We reviewed the peripartum records of all parturients with the diagnosis of AS who were treated in Shaare Zedec Medical Center (Jerusalem, Israel) and Mount Sinai (Toronto, Canada) between the years 1990 and 2005. Demographic data, etiology of AS, NYHA functional class, results of cardiac echography, mode of delivery, anesthetic management, peripartum monitoring, fluids and complication were summarized and presented in tabular form. The severity of AS was classified as moderate (valve area 0.8 to 1.2 cm2 and peak gradient 35-64 mmHg) and severe (valve area 64mmHg).(1) Results: There were six patients with moderate AS and six with severe AS (table). 5/6 parturients with moderate AS had regional anesthesia for either vaginal delivery or cesarean section. 3/6 parturients with severe AS had regional anesthesia. 4 patients with severe AS and 2 with moderate AS had invasive blood pressure monitoring. One patient with critical symptomatic AS had intraoperative transesophageal echocardiography (TEE) under general anesthesia. There were no anesthetic complications (except one failed epidural) or hemodynamic instability. Discussion: Traditionally, neuraxial anesthesia has been contraindicated in patients with AS because of the fear that a sudden decrease in systemic vascular resistance may precipitate severe hypotension in the face of fixed cardiac output.(2) The anesthetic management of patient with AS focuses on hemodynamic stability.(3) The use of a slowly titrated epidural or combined spinal-epidural with reduced dose of spinal anesthesia, may provide this stability in all except possibly the most severely affected parturients. The management of some patients with AS may be facilitated by invasive monitoring. Special attention to postoperative analgesia, monitoring and volume status may prevent hemodynamic instability and complications. 1-Silversides CK The American Journal of Cardiology 2003;91;1386-89. 2-Stoelting RK Anesthesia and Coexisting Disease. 2002:38-40. 3-McDonald SB Regional Anesthesia and Pain Med. 2004; 29; 496-502.

INTRODUCTION: Needle redesign revolutionized spinal anesthesia by producing large reductions in postdural puncture headache (PDPH). Epidural needles now represent the leading cause of severe PDPH after regional anesthesia. Further success in prevention is most likely to come from use of smaller gauge epidural needles. 20g epidural steroid injection has a reported PDPH incidence of 9.8% (1)compared with > 70% with larger needles. 20g epidural needles produce a 4-5 fold reduction in CSF leak compared with current needles following puncture(2) and clinical work suggests that blood patch is more successful for smaller gauge punctures (3). This trial examined the feasibility of using mini-gauge Tuohy needles and catheters for continuous epidural labour analgesia.

Anaesthetic management for Caesarean section in a pre-eclamptic patient with Ebstein's anomaly and a right to left intracardiac shunt was accomplished under general anaesthesia. Air bubbles in the venous line were meticulously eliminated to prevent paradoxical air emboli. A rapid sequence induction using standard doses of thiopentone and succinylcholine did not result in loss of consciousness and muscle relaxation was inadequate for endotracheal intubation. This problem must be anticipated in patients with extremely enlarged right atria and the dose of induction agents should be increased. Carefully controlled epidural anaesthesia may be used if the cardiac reserve is adequate.

The anaesthetic management of two patients with uncontrolled hyperthyroidism requiring Caesarean section is described. The first patient was diagnosed as hyperthyroid during pregnancy but was resistant to medical management with propylthiouracil (PTU). At 38 weeks' gestation, after optimizing her heart rate with intravenous propranolol, she received an epidural anaesthetic for the Caesarean section. The baby had manifestations of hypothyroidism immediately after birth but later became hyperthyroid. The second patient's hyperthyroidism was well controlled but she stopped her medication one week before delivery. The Caesarean section was performed under general anaesthesia for fetal distress. The baby died in the neonatal period of extreme prematurity. The anaesthetic management of the hyperthyroid parturient is discussed. Preoperative control of hyperthyroidism, bearing in mind pregnancy and time constraints, is essential. The use of PTU, propranolol, iodine, and glucocorticoids is described in the preparation of the parturient. Fetal and neonatal effects of these drugs are discussed.

We report the failure of a test dose of 3 ml lidocaine 1.5 per cent with 15 micrograms epinephrine to identify subdural placement of an epidural catheter in a parturient. Thirty-five minutes after injection of 13 ml lidocaine 1.5 per cent, intended to provide epidural analgesia, the patient developed an extensive sensory neural blockade. Some motor control was maintained and sympathetic block was incomplete. Blood pressure and oxygenation were easily supported with optimum positioning, fluids, ephedrine and oxygen by mask. The patient remained alert. The duration of neural blockade was approximately two hours. The patient underwent a second epidural for labour analgesia that was uneventful. There were no sequelae. Subdural injections are uncommon and unpredictable in their occurrence. Test doses do not consistently identify misplaced catheters. A negative response to a test dose does not guarantee that extensive neural blockade will not occur during epidural analgesia.