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Background: There is no information about the distribution of pethidine into breast milk and/or exposure of the breastfed infant during pethidine patient-controlled epidural analgesia after caesarean delivery., Methods: We conducted an observational study among 20 women. The mean (95% confidence interval) pethidine dose administered was 670 (346-818) mg over 41 (35-46) h. Maternal plasma and milk and neonatal plasma were collected near the time of pethidine cessation and 6h later. Absolute and relative infant doses via milk and infant exposure were calculated. Infant behaviour was assessed using the Neurologic and Adaptive Capacity Score., Results: At first and second sampling times, mean absolute infant doses for pethidine were 20 (14-27) μg/kg/day and 10 (7-13) μg/kg/day, while mean relative infant doses were 0.7 (0.1-1.4)% and 0.3 (0.1-0.5)% respectively. Similar values for norpethidine (expressed as pethidine equivalents) were 21 (16-26) μg/kg/day and 22 (12-32) μg/kg/day; and 0.7 (0.3-1)% and 0.6 (0.2-1)% respectively. Mean pethidine and norpethidine concentrations in neonatal plasma were 3 (0-6.1) μg/L and 0.6 (0.2-1) μg/L. Compared with a time-matched maternal sample, the infant's exposure was 1.4 (0.2-2.8)% for pethidine and 0.4 (0.2-0.6)% for norpethidine. The mean (95% confidence interval) neurologic and adaptive capacity score was 33.6 (32.2-34.9)., Conclusion: The combined absolute infant dose of pethidine and norpethidine received via milk was 1.8% of the neonatal therapeutic dose and the combined relative infant dose was below the 10% recommended safety level. Breastfed infants are at low risk of drug exposure when mothers self-administer epidural pethidine after caesarean delivery., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Introduction: Approximately 50% of women experience nausea or vomiting during labour. P6 acupoint stimulation reduces postoperative nausea and vomiting in early pregnancy and after chemotherapy. The aim of this randomised, double-blinded, placebo-controlled trial was to determine whether P6 acupressure prevented nausea and vomiting during labour and delivery., Methods: After ethical approval and informed consent, women admitted for induction of labour, or in spontaneous labour, were randomised to receive either acupressure bands (Pressure Right) (Group A) or sham placebo bands (Group P) applied to each wrist. Exclusions included recent nausea or vomiting., Results: We consented 365 women and randomised 340 (170 per group). The groups had similar patient and labour characteristics. The incidence of nausea and/or vomiting did not significantly differ (Group A 53% vs. Group P 50%, P=0.58). There was no significant difference between groups (A vs. P, respectively) in the incidence of nausea (52% vs. 45%), vomiting (27% vs. 28%), rescue antiemetic treatment (27% in both), severity of nausea or vomiting, satisfaction with control of nausea or ratings of inconvenience or discomfort from the bands (10% vs. 11%). Factors significantly associated with emetic symptoms were smoking (OR 2.16, 95% CI 1.07-4.37), opioid analgesia (OR 1.95, 95% CI 1.06-3.59), history of motion-induced or postoperative nausea and vomiting (OR 1.85, 95% CI 1.17-2.94) and higher body mass index (OR 1.07, 95% CI 1.01-1.12)., Conclusion: In this study acupressure wristbands applied bilaterally did not reduce the incidence of nausea and vomiting during labour and delivery., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background: Hypotension after spinal anaesthesia is a common and important complication at caesarean delivery. Skin conductance monitoring has been shown to predict post-spinal hypotension in elderly patients and may be a rapid, non-invasive means of predicting risk in the obstetric population., Methods: Women having elective caesarean delivery were included in this observational pilot trial. Baseline data were obtained for blood pressure, heart rate and skin conductance variables before administration of spinal anaesthesia and at 1-min intervals for 20 min thereafter. Correlations between baseline data and minimum post-spinal blood pressure were calculated, and the predictive value of baseline variables was estimated by use of receiver operator characteristics., Results: Forty women completed the study. Spinal anaesthesia was followed in most cases by a significant reduction from baseline in systolic blood pressure [0-9% n=2 (5%), 10-20% n=21 (52.5%), 20-30% n=12 (30%), >30% n=5 (12.5%)]. Minimum systolic blood pressure was >100 mmHg in 25 (62%), 80-100 mmHg in 12 (30%) and < 80 mmHg in 3 (7.5%) patients. Fasting times, spinal block distribution, baseline heart rate, blood pressure or baseline skin conductance did not predict post-spinal hypotension or neonatal outcome., Conclusion: In contrast to a previous report in elderly patients, we were unable to demonstrate a significant relationship between baseline sympathetic tone, measured by skin conductance, and hypotension following spinal anaesthesia in women undergoing elective caesarean delivery., (2010 Elsevier Ltd. All rights reserved.)

Magnesium is commonly used in the prevention of eclampsia. Reports of acute toxicity are rare and we are not aware of detailed management algorithms. We present a case of acute magnesium toxicity presenting as ventilatory impairment and failure to rouse adequately from general anaesthesia. The patient was managed with controlled ventilation, further sedation, intravenous calcium gluconate, forced diuresis and dextrose-insulin infusion. We present a guideline for the management of life-threatening magnesium toxicity and discuss measures that may prevent future similar occurrences., (Crown Copyright 2009. Published by Elsevier Ltd. All rights reserved.)

Background: Clinically overt infections of the epidural catheter skin entry site occur in approximately 1-5% of patients after a few days of catheterization but serious complications such as deep tissue infection or epidural abscess appear rare in the obstetric population. In recent years, sporadic reports and small series suggest that the incidence may be higher than previously estimated., Methods: A retrospective chart review was conducted to identify epidural catheter-related infections occurring between January 2002 and December 2005 in a tertiary referral maternity hospital delivering between 4000 and 6000 women per annum. Cases were identified using International Statistical Classification of Diseases coding., Results: In total 9482 women (52.8%) who delivered had an epidural catheter inserted. There were 258 cases with the relevant code identified and 49 (0.52%, 95% CI 0.37-0.66%) had epidural catheter-related infection. Four women had deep tissue infection (incidence 0.04%, 95% CI 0.01-0.11%; rate 1 in 4741), represented by paraspinous and epidural abscess formation (incidence of both 0.02%, 95% CI 0-0.08%; rate 1 in 2371). Three of the cases are described., Conclusions: Serious epidural catheter-related infection in obstetric patients is rare, but our incidence of serious deep tissue infection was at the upper extreme of figures quoted in other studies., (Crown Copyright 2009. Published by Elsevier Ltd. All rights reserved.)

Background: Primary post-caesarean analgesia based on oral opioid has not been adequately studied. This approach may show a good side-effect profile and high satisfaction and avoid neuraxial complications., Methods: In a double-blind, double-dummy, placebo-controlled clinical trial 120 women were randomised to receive either sustained-release oral oxycodone 20mg in the recovery room followed by immediate-release oxycodone 10mg 6-hourly for the first 24h (group O) or intrathecal morphine 100mug at the time of spinal anaesthesia (group I). All women received regular postoperative diclofenac, paracetamol and standardised supplemental analgesia., Results: One hundred and eleven women completed the study. The area under the curve for pain scores to 24h did not differ significantly between groups for pain at rest (P=0.465) or on movement (P=0.533). Numerical pain scores were low and similar, except at rest at 12h (group I 1 [0-2] vs. group O 2 [1-3]; P=0.030). The time to first analgesic request was similar but additional postoperative analgesics were required more often in group O (82% vs. 63%, P=0.034). Group O more frequently reported high worst pain scores (score 4-10 in 87% vs. 64%, P=0.007). Pruritus was more common and more severe in group I (87% vs. 56%, P=0.001). At 24h maternal satisfaction with the analgesic regimen was lower in group O (P=0.010)., Conclusion: Oral oxycodone produced comparable postoperative pain relief to intrathecal morphine with a lower incidence of pruritus, but was associated with a lower satisfaction score., (Crown Copyright 2009. Published by Elsevier Ltd. All rights reserved.)

Background and Objective: An estimated 150 million people worldwide use cannabis. The effect of cannabis on anaesthetic requirements in humans does not appear to have been studied., Methods: In this prospective, randomized, single-blinded study, 30 male patients using cannabis more than once per week (group C) and 30 nonusers (group NC), aged 18-50 years, were induced with propofol 1.5, 2, 2.5, 3 or 3.5 mg kg. Additional doses were given when required. The primary outcome was the 50% effective dose of propofol and successful induction was determined by loss of consciousness with a bispectral index value of less than 60 and satisfactory insertion of a laryngeal mask. Propofol requirements to achieve these outcomes were recorded., Results: The dose required to achieve the target bispectral index value was not significantly higher in group C, but group C required a significantly higher propofol dose to achieve laryngeal mask insertion (314.0 +/- 109.3 vs. 263.2 +/- 69.5 mg, P < 0.04). The estimated effective propofol induction dose in 50-95% of patients did not significantly differ between groups., Conclusion: We conclude that cannabis use increases the propofol dose required for satisfactory clinical induction when inserting a laryngeal mask.

Background: Recent developments in anaesthesia and patient demographics have potentially changed the practice of obstetric general anaesthesia. There are few contemporary data on Australasian practice of general anaesthesia for caesarean section, especially relating to airway management, anaesthetic techniques and complications., Methods: Using a standardised case record form, a prospective observational study was conducted during 2005-06 in 13 maternity hospitals dealing with approximately 49 500 deliveries per annum. Patient demographics, airway management, anaesthetic techniques and major complications were evaluated in those given general anaesthesia., Results: Data were obtained from 1095 women receiving general anaesthesia for caesarean section, 47% of which were classified as category 1 and 18% as category 4. Tracheal intubation was planned in all cases with rapid-sequence induction used in 97%. A grade 3 or 4 laryngoscopic view was obtained in 3.6 and 0.6% of cases respectively, with 3.3% considered a difficult intubation. There were four failed intubations (0.4%, 95% CI 0.01-0.9%), of which three were subsequently managed using a laryngeal mask airway. Antacid prophylaxis was used in 94% of elective cases and 64% of emergencies. Regurgitation of gastric contents was noted in eight cases (0.7%, 95% CI 0.2-1.2%), with one confirmed case of aspiration (0.1%, 95% CI 0.002-0.5%). There were no cases of serious airway-related morbidity., Conclusions: General anaesthesia is most commonly used in emergency situations. Tracheal intubation after rapid-sequence induction remains the predominant approach to airway management in Australasia. The incidence of failed intubation is consistent with previous studies. Aspiration prophylaxis is not routinely used for emergency surgery.

Background: Refractory postoperative nausea and vomiting (PONV) requiring repeated treatment with antiemetic drugs is a miserable experience for the patient that may substantially increase the cost of care. As risk stratification may aid in prophylaxis and treatment, we explored risk factors for severe PONV in patients enrolled in a large international, randomized controlled trial (the ENIGMA trial)., Methods: Two thousand and fifty patients, aged > or =18 yr and undergoing surgery anticipated to exceed 2 h in duration, were recruited. Patients were randomized to nitrous oxide (N(2)O)-based or N(2)O-free anaesthesia. Choice of other anaesthetic, analgesic, and antiemetic drugs was left to the discretion of the anaesthetist. Anaesthetic depth was adjusted according to clinical judgement and, if available, bispectral index (BIS) monitoring. Severe PONV was defined as: (i) two or more episodes of expulsion of gastric contents at least 6 h apart; (ii) received at least three doses of antiemetic medication for treatment of PONV, within 24 h of surgery; or both. We used logistic regression, and classification and regression tree analysis, to define risk factors for severe PONV., Results: Three hundred and thirty-three (16.6%) patients experienced severe PONV. Age <55 yr, female sex, abdominal surgery, N(2)O administration, absence of BIS monitoring, and longer duration of anaesthesia were predictors of severe PONV [area under receiver operating characteristic curve=0.70 (95% confidence interval: 0.67-0.73)]., Conclusions: Severe PONV was common and risk factors for it were similar to those reported in other studies that included all patients reporting nausea, vomiting, or both.

Background: The obstetric population is considered at high risk of awareness and recall when undergoing general anaesthesia for caesarean section. In recent years the incidence may have been altered by developments in obstetric anaesthesia., Methods: A prospective observational study of general anaesthesia for caesarean section was conducted during 2005 and 2006 in 13 maternity hospitals dealing with approximately 49,500 deliveries per annum in Australia and New Zealand. As a component of this study the frequency of recall of intraoperative events was examined using a structured postoperative interview on two occasions., Results: There were 1095 general anaesthetics surveyed with 47% being performed for urgent fetal delivery. Thiopental was the most common induction agent (83%) with sevoflurane being used for maintenance in 63%. In 32% of cases a depth-of-anaesthesia monitor was used. In 763 cases (70%) there was least one postoperative interview enquiring into dreaming and awareness. There were two cases deemed to be consistent with awareness (incidence 0.26%, CI 0.03-0.9%, or 1 in 382) and three cases of possible awareness., Conclusion: Awareness with recall of intraoperative events remains a significant complication of obstetric general anaesthesia but was potentially avoidable in all cases detected in this study.

Background: Arousal after total i.v. anaesthesia (TIVA) has been reported to be detectable by monitoring the number of fluctuations per second (NFSC), a parameter of skin conductance (SC). However, compared with monitoring of the bispectral index (BIS), the predictive probability of NFSC was significantly lower. The aim of this study was to determine the value of the two new, not yet published parameters of SC, area under the curve (AUC) methods A and B, for monitoring emergence from TIVA compared with monitoring of NFSC and BIS., Methods: Twenty-five patients undergoing surgery were investigated. NFSC, AUC A, AUC B, BIS, and haemodynamic parameters (mean arterial pressure and heart rate) were recorded simultaneously. The performance of the monitoring devices in distinguishing between the clinical states 'steady-state anaesthesia', 'first clinical reaction', and 'extubation' were compared using the method of prediction probability (Pk) calculation., Results: BIS showed the best performance in distinguishing between 'steady-state anaesthesia' vs 'first reaction' (Pk BIS 0.95; NFSC 0.73; AUC A 0.54; AUC B 0.62) and 'steady-state anaesthesia' vs 'extubation' (Pk BIS 0.99; NFSC 0.73; AUC A 0.71; AUC B 0.67). However, the time from first BIS>60/SC>0 to a first clinical reaction was significantly shorter for BIS (median BIS((R)) 180 s; NFSC 780 s; AUC A 750 s; AUC B 690 s; P < 0.001)., Conclusions: AUC A and AUC B did not improve accuracy of SC monitoring in patients waking after TIVA.

Background: Arousal after sevoflurane anaesthesia has been detectable by monitoring changes in skin conductance (SC) with similar accuracy as monitoring Bispectral Index (BIS). As SC monitoring detects changes in sympathetic tone, the measurements might be confounded by the sympatholytic properties of propofol, a component of total i.v. anaesthesia (TIVA). Therefore in this study, monitoring of SC during emergence from TIVA was compared with the monitoring of BIS., Methods: Twenty-five patients undergoing plastic surgery were investigated. The number of fluctuations of SC per second (NFSC), BIS and haemodynamic variables [systolic blood pressure (SBP) and heart rate (HR)] were recorded simultaneously. The performance of the monitoring devices in distinguishing between the clinical states 'steady-state anaesthesia', 'first clinical reaction' and 'extubation' were compared using the method of prediction probability (Pk) calculation., Results: BIS((R)) showed the best performance in distinguishing between 'steady-state anaesthesia' and 'first reaction' (Pk BIS 0.99 vs NFSC 0.80; P<0.01), and 'steady-state anaesthesia' and 'extubation' (Pk BIS) 1.00 vs NFSC 0.91; P<0.05); the time from first change of BIS or NFSC to a first clinical reaction was significantly longer for NFSC (median BIS 135 s vs NFSC 191 s; P<0.05). BIS and NFSC performed better in distinguishing between the investigated clinical states than SBP and HR., Conclusions: In this study, BIS was found to predict arousal with a higher probability but slower response times than NFSC in patients waking after TIVA.

Background: Pain is known to alter the electrogalvanic properties of the skin. The aim of this pilot study was to investigate the influence of postoperative pain on skin conductance (SC) readings., Methods: After obtaining ethical approval and written informed consent, 25 postoperative patients were asked to quantify their level of pain on a numeric rating scale (NRS, 0-10) at different time points in the recovery room. As a parameter of SC, the number of fluctuations within the mean SC per second (NFSC) was recorded. Simultaneously, the NRS was obtained from patients by a different observer who was blinded to the NFSC values., Results: Data from 110 readings of 25 patients (14 female, 11 male; 21-67 yr) were included. NFSC showed a significant correlation with the NRS (r=0.625; P<0.01), whereas heart rate and blood pressure showed no or very weak correlation with the NRS. NFSC was significantly different between patients with no (NRS=0), mild (NRS=1-3), moderate (NRS=4-5) and severe (NRS=6-10) pain (no: 0.047, mild: 0.089, moderate: 0.242, severe: 0.263; P<0.0001). Post hoc, a cut-off value for NFSC (0.1) was calculated above which a pain score >3 on the NRS was predicted with sensitivity of 89% and specificity of 74%., Conclusions: The severity of postoperative pain significantly influences SC. Using cut-off values, NFSC may prove a useful tool for pain assessment in the postoperative period.

A pregnant woman with severe hypertrophic cardiomyopathy was monitored with transthoracic echocardiography to guide management of fluids and vasopressors during elective caesarean section. After insertion of intravenous, arterial and central venous cannulae, a transthoracic echocardiogram was performed noting left ventricular cavity size and contractility, systolic anterior motion of the mitral valve and left ventricular outflow tract obstruction. Following combined spinal-epidural anaesthesia, serial examinations were made intraoperatively. Short-lived haemodynamic instability ensued just before the incision and with administration of oxytocin. Her postoperative course was complicated by post-partum haemorrhage requiring radiological intervention but she ultimately recovered fully. Maintaining preload to avoid worsening of left ventricular outflow tract obstruction is essential in these patients. A transthoracic echocardiogram is easily performed, of low risk and provides more useful information than a pulmonary artery catheter.

Background: Changes in skin conductance have previously been reported to correlate well with plasma levels of stress hormones and awakening stimuli. In this study, monitoring of skin conductance during emergence from general anaesthesia was compared with the monitoring of bispectral index (BIS)., Methods: Twenty-five patients undergoing minor elective surgery were investigated. The number of fluctuations in mean skin conductance (NFSC), BIS and haemodynamic parameters were recorded simultaneously. The performance of the monitoring devices to predict and distinguish between the clinical states 'steady-state anaesthesia', 'first reaction' and 'extubation' were compared using the method of prediction probability (P(K)) calculation., Results: Both monitors showed similar performance in distinguishing between 'steady-state anaesthesia' vs 'first reaction' (P(K) NFSC 0.89; BIS 0.94) and 'steady-state anaesthesia' vs 'extubation' (P(K) NFSC 0.96; BIS 0.96). The response times of the monitors, to indicate the likelihood of 'first reaction', were not significantly different., Conclusions: NFSC, as a parameter of skin conductance, performed similarly to BIS in patients waking after a general anaesthetic.

We present the case of a 30-year-old parturient diagnosed in the first trimester of her first pregnancy as having paroxysmal nocturnal haemoglobinuria. Pancytopenia necessitated regular transfusion of blood products. The risks of infection, haemorrhage and thrombosis, in the presence of severe thrombocytopenia, mild neutropenia and prophylactic anticoagulation, posed management challenges. We discuss the pathophysiology of paroxysmal nocturnal haemoglobinuria and the impact of pregnancy on the disorder, particularly on maternal morbidities such as thrombosis. The issues relevant to antenatal and peripartum obstetric, haematological and anaesthetic care for vaginal delivery are considered. Severe thrombocytopenia proved a contraindication to regional techniques and she required general anaesthesia for evacuation of a retained placenta. The post-partum period was complicated by fever and a requirement for blood products. Management of these problems, of prophylactic anticoagulation and subsequent therapy, are discussed.

Fentanyl is commonly used for spinal analgesia during labour but it is associated with a high incidence of pruritus. This randomised, double-blind, placebo-controlled study was performed to evaluate the effect of prophylactic ondansetron on the incidence and severity of pruritus among parturients receiving intrathecal fentanyl as part of combined spinal-epidural analgesia. Seventy-three women were randomised to receive either saline placebo (group P, n = 25), ondansetron 4 mg (group O4, n = 23) or ondansetron 8 mg (group O8, n = 25) intravenously before intrathecal fentanyl 25 micrograms and bupivacaine 2 mg. The incidence and severity of pruritus were measured using a verbal rating and a visual analogue scale, and by the requirement for rescue anti-pruritic medication (naloxone). The overall incidence of pruritus was 95% (group P 100%, group O4 95%, group O8 90%). There were no significant differences between groups for severity of pruritus or requirement for treatment (naloxone given to 45%, 28% and 35% of groups P, O4 and O8 respectively). Secondary outcomes such as the incidence of headache, pain and nausea were not significantly different between groups. We conclude that prophylactic ondansetron 4 or 8 mg intravenously was ineffective in reducing the incidence or severity of intrathecal fentanyl-induced pruritus during labour.

There are currently three 5-hydroxytryptamine3 (5-HT3) receptor antagonists available in Australia. In this randomized, double-blind, parallel group study the prophylactic antiemetic effect of a single dose of tropisetron 2 mg, ondansetron 4 mg or dolasetron 12.5 mg was compared after major gynaecological surgery. One hundred and eighteen patients (group T n = 42; group O n = 36; group D n = 40) were evaluated for nausea, vomiting, recovery characteristics and satisfaction for 24 hours postoperatively. A cost-effectiveness analysis was performed. Rescue antiemetic, prochlorperazine 12.5 mg i.m., was given if vomiting occurred more than 10 minutes after arrival in the recovery room. If prochlorperazine was ineffective one hour after administration, droperidol 1 mg i.v. was given. There were no significant differences between groups for the incidence of vomiting during consecutive epochs until 24 hours postoperatively or overall (57%, 75% and 72.5% for groups T, O and D respectively, P = 0.18). The incidence and number of rescue antiementic treatments for nausea or vomiting were similar. The incidence of nausea and the overall and interval nausea scores were similar except for lower "worst nausea" score in group T between 12 and 18 hours (P = 0.02). Recovery times, satisfaction and cost per patient did not differ between groups. We conclude that the risk of postoperative nausea and vomiting remained high in this setting despite 5-HT3 receptor antagonist prophylaxis and that the choice between these agents should be based on the lowest available acquisition cost.

Nonsteroidal antiinflammatory drugs, including ketorolac, are widely used for postoperative analgesia. This randomized, double-blinded trial compared IV ketorolac or saline combined with meperidine patient-controlled epidural analgesia (PCEA) after cesarean delivery. Fifty healthy parturients scheduled for elective cesarean delivery under combined spinal-epidural anesthesia received PCEA plus either IV ketorolac (Group K) or saline (Group C) for 24 h. The ketorolac dose was modified, after six patients had been studied, based on new product information recommending a maximum of 120 mg ketorolac over 24 h. Group K (n = 24) and Group C (n = 20) were demographically similar. During the first 24 h, Group K used significantly less meperidine (P < 0.05). Postoperative pain at rest and with movement, and patient satisfaction, did not differ significantly between groups, except that worst pain at 12 h was less in Group K (P < 0.005). The two groups were similar with respect to patient recovery and side effects. IV ketorolac, as an adjunct to PCEA after cesarean delivery, produced a meperidine dose-sparing effect of approximately 30%, but did not significantly improve pain relief, reduce opioid-related side effects, or change patient outcome.

Background and Objectives: The effectiveness of local anesthetic wound infiltration for treatment of postoperative pain appears to be variable and partly dependent on the surgical procedure. Although evidence was lacking, it was common practice at our institution to infiltrate the trocar wound of patients undergoing day-case laparoscopic procedures with long acting local anesthetic agents. The aim of this study was to investigate the analgesic efficacy, and the influence of the timing, of local anesthetic infiltration into surgical wounds for day-case diagnostic gynecological laparoscopy., Methods: A double-blind, randomized trial was conducted on 100 women having general anesthesia for day-case gynecological laparoscopy. Ninety-two patients who had been randomized to 1 of 4 groups for trocar wound infiltration with 30 mL of 0.25% bupivacaine or saline either before or after surgery completed the study. Incisional pain, pain on pressing the umbilicus, severity of nausea, and patient satisfaction with anesthetic technique were all assessed postoperatively until discharge and on the following day through a telephone interview. A P value of <.05 was considered significant., Results: There was no difference between groups in the mean pain scores or analgesic requirements for incisional pain, pain on pressing firmly on the umbilicus, or for patient satisfaction. There was a trend for those patients who had received bupivacaine to use less postoperative morphine (P =.079)., Conclusions: Wound infiltration with local anaesthetic did not significantly reduce pain or opioid requirement after gynecological laparoscopy.

Objective: To investigate whether adverse effects in a premature neonate could be attributed to nefazodone exposure via breast milk., Case Summary: The breast-fed white infant (female, 2.1 kg, 36 weeks corrected gestational age) of a 35-year-old woman (60 kg) taking nefazodone 300 mg/d was admitted to the hospital because she was drowsy, lethargic, unable to maintain normal body temperature, and was feeding poorly. A diagnosis of exposure to nefazodone via breast milk was considered only after other more likely diagnoses had been excluded. After breast feeding was discontinued, the infant's symptoms resolved slowly over a period of 72 hours. The maternal plasma and milk concentration-time profiles for nefazodone and its metabolites, triazoledione, HO-nefazodone, and m-chlorphenylpiperazine, were quantified by HPLC. The calculated infant dose for nefazodone and its active metabolites (as nefazodone equivalents) via the milk was only 0.45% of the weight-adjusted maternal nefazodone daily dose., Discussion: Our data suggest a putative association between maternal nefazodone ingestion and adverse effects in a premature breast-fed neonate. The measured amount of drug exposure would normally be considered safe in a full-term infant. However, there was a temporal relationship between resolution of adverse effects in the infant and cessation of breastfeeding., Conclusions: This case highlights the importance of individualizing the risk-benefit analysis for exposure to antidepressants in breast milk, especially when dealing with premature neonates.

A randomised, blinded clinical trial was performed to evaluate intraspinal opioid analgesic techniques after caesarean section. Healthy term parturients having elective caesarean section under combined spinal-epidural anaesthesia were allocated to one of three groups. Postoperative analgesia, including non-steroidal anti-inflammatory drugs, was provided using either pethidine patient-controlled epidural analgesia (group PCEA) or subarachnoid morphine 200 microg, the latter supplemented as required with patient-controlled intravenous pethidine (group SMPCIA) or oral paracetamol and codeine (group SMO). Maternal analgesia, side effects, recovery and satisfaction were assessed for 48 h. Of 144 parturients enrolled, 137 completed the study (PCEA n = 44, SMPCIA n = 45, SMO n = 48). The groups were demographically similar. All participants experienced good pain relief, including median visual analogue pain scores (0-100) with movement <40 between 0-24 h. However, pain scores were significantly lower at 8 and 12 h in those receiving subarachnoid morphine (P< 0.05). Women in groups receiving subarachnoid morphine experienced more severe pruritus (P<0.001), nausea (P< 0.001) and drowsiness (P< 0.05). Postoperative recovery of bowel function and ambulation occurred earlier in those using PCEA, although this did not appear to be of clinical significance. Patient satisfaction was similar, although women in group SMO were least likely to choose this approach again (P<0.05). We concluded that all three techniques provided effective analgesia for a prolonged period postoperatively. Better pain relief, but more opioid-related side effects, resulted from subarachnoid morphine 200 microg, and re-evaluation of reduced doses of subarachnoid morphine may be warranted.

Background and Objectives: Epidural clonidine has not been evaluated as a component of patient-controlled epidural analgesia (PCEA) solutions during labor. A randomized, double-blind trial was conducted to investigate the efficacy and side effects of PCEA using bupivacaine and fentanyl, with or without clonidine., Methods: Seventy-five healthy parturients in active labor were assigned to a PCEA solution of 0.0625% bupivacaine and fentanyl 2 microg/mL (4 mL demand bolus, 15 min lockout), with or without clonidine 4.5 microg/mL. The primary outcome measure was parturient rating of analgesia; others assessments included pain scores, drug utilization, supplementation and side effects., Results: Thirty-one parturients received clonidine (group BFC) and 38 received control solution (group BF). Eight (6 group BF, 2 group BFC, P = .28) failed to achieve satisfactory epidural analgesia. There was a trend for parturient ratings of pain relief to be higher in group BFC, with significantly more reporting excellent first-stage analgesia (81% v. 57%, P<.05). Pain scores were similar. Clonidine (median dose, 28 microg/h) reduced total bupivacaine and fentanyl use (P<.01), and reduced supplementation (P<.01). Maternal blood pressure (BP) and recordings of systolic BP below 100 mm Hg did not differ. Group BFC had higher sedation scores (P<.01), but no one appeared oversedated. Shivering was reduced in group BFC (P<.01)., Conclusions: The addition of clonidine to epidural bupivacaine and fentanyl for PCEA in labor improved analgesia, reduced the supplementation rate, and reduced shivering. Increased sedation and lower BP were not clinically important.

We describe a 27-year-old woman with osteogenesis imperfecta who, over a period of 9 years, underwent five caesarean sections under regional anaesthesia without major complication. The first three operations were conducted under epidural and the last two under spinal anaesthesia. To our knowledge, this is the first reported case of spinal anaesthesia for caesarean section in a parturient with osteogenesis imperfecta.

The use of epidural analgesia (EA) during labour is increasing in Australasia. This highlights the need for improved educational and resource materials, current factual information about EA, and identification of consumer attitudes towards EA. In this survey, 350 parturients who had recently used EA for labour pain relief in a single maternity unit were asked to complete a questionnaire about their expectations and experience. The response rate was 90%. Prepartum information was most commonly derived from hearsay and least commonly from medical health professionals, 56% of respondents wanted pain to be made tolerable and 34% wanted complete pain relief. Almost half considered unrestricted mobility and delivery without obstetric assistance important. A minority were concerned about possible effects of EA on the baby or labour outcome. Anticipated pain during epidural placement was significantly greater than that experienced. Satisfaction with EA was high, although 36% described unpleasant or annoying effects associated with EA. Parent educators and epidural service providers should be aided by knowledge of where parturients obtain information and of consumer views about EA.

Although epidural anaesthesia and analgesia are widely used in obstetrics, there are no large contemporary prospective series detailing associated complications. Prospective data was collected on all obstetric epidural blocks performed for labour and delivery in a single institution between July 1989 and August 1994. A data entry sheet was compiled and entered onto a computer database. Confidence intervals for proportions were calculated using standard methods. Information from 10 995 epidural blocks was analysed. Epidural analgesia in labour was the primary indication in 7648, and anaesthesia for caesarean section in 3311. Minor complications included failed or abandoned insertion (incidence 0.5%), reinsertion of the epidural catheter (5%), and inadequate anaesthesia (1.7%) or analgesia (0.9%). Three percent were associated with venous puncture and 0.6% with accidental dural puncture. Maternal mortality was zero. Unexpectedly high blocks occurred on eight occasions (0.07%), two requiring intubation and ventilation. Three women (0.06%) experienced mild respiratory depression after postoperative epidural opioid. There was no major local anaesthetic toxicity or neurological deficit. The incidence of potentially life-threatening morbidity was thus 0.02% although in both cases outcome was good. The only persisting complication was neurological, an apparent epidural catheter-induced traumatic mononeuropathy.

Water intoxication during pregnancy is an uncommon event, usually associated with iatrogenic fluid overload, the prolonged administration of high doses of oxytocin or psychiatric disorder. This case report describes water intoxication presenting as the sudden onset of grand mal convulsions in the immediate postpartum period, after a normal delivery in a healthy parturient. The most likely explanation was an excessive voluntary ingestion of large quantities of water and hypotonic fluids during labour.

Unlabelled: Epidural anesthesia (EA) and combined spinal-epidural anesthesia (CSEA) are popular anesthetic techniques for elective cesarean section. A randomized, blind study was conducted to compare maternal experiences during these regional anesthetics. EA was established using alkalinized 2% lidocaine with epinephrine and fentanyl, whereas spinal anesthesia was performed using 2.5 mL hyperbaric 0.5% bupivacaine and fentanyl via a single-space CSEA approach. Both patients and observers were blinded to the anesthetic technique allocation. One hundred twenty patients were enrolled; 6 were withdrawn (Group EA, n = 55; Group CSEA, n = 59). Of the two techniques, CSEA was associated with earlier onset times (P < 0.001), more intense motor block (P < 0.05), and greater ephedrine use (P < 0.01). Anxiety was significantly lower (P < 0.05) and satisfaction was higher (P < 0.05) before starting surgery with CSEA. Pain scores were lower pre- and intraoperatively with CSEA, a difference that became significant during block placement and at delivery (P < 0.05). There were no differences between groups in the incidence or severity of hypotension and nausea or analgesic supplementation rate; or for postoperative assessments of intraoperative pain, anxiety and satisfaction, and postpartum backache and headache. We conclude that maternal conditions and experience were good with both methods, although CSEA conferred several minor advantages., Implications: Epidural and combined spinal-epidural anesthesia are often used for elective cesarean sections. Although the combined spinal-epidural anesthetic technique conferred minor advantages, both techniques were associated with low anesthetic failure rates, good operative conditions, and high maternal satisfaction levels.

Background and Objectives: Neurologic deficits after spinal and epidural anesthesia are uncommon and have a variety of pathophysiologic mechanisms. Local anesthetic neurotoxicity may occur, although subarachnoid bupivacaine has an unblemished clinical record., Methods: A healthy parturient underwent uneventful combined spinal and epidural anesthesia for elective cesarean delivery. Intraspinal drugs administered included hyperbaric bupivacaine 0.5% and fentanyl (subarachnoid) and 2% lidocaine with epinepherine 1:200,000 and meperidine (epidural)., Results: On the third postpartum day the patient reported buttock numbness. An area of hypoesthesia in the distribution of the lower sacral nerves was present, without systemic or other neurologic symptoms and signs. The deficit persisted, and imaging of the lower spinal canal revealed no significant abnormality. Full recovery of sensation occurred after 7 months., Conclusion: Drug-induced neurotoxicity is a possible explanation, although the exact etiology is uncertain.

The aim of this randomized, double-blind trial of postoperative thoracic epidural analgesic infusions was to determine whether clonidine at 10 microg/h (group C10, n = 22), 15 microg/h (Group C15, n = 24), or 20 microg/h (Group C20, n = 24) improved postoperative analgesia in patients undergoing abdominal gynecologic surgery, without side effects or hemodynamic changes, when added to a 5-mL/h infusion of 0.125% bupivacaine and fentanyl 2 microg/mL (Group CO, n = 22). The 24-h study infusion was supplemented, as required, by patient-controlled epidural fentanyl. Groups were similar for age, weight, duration, and type of surgery. Clonidine produced a dose-dependent improvement in analgesia at rest. Only 20 microg/h significantly increased the percentage of patients who experienced no pain with coughing (relative risk 1.44, 95% confidence interval 1.24-1.94), reduced pain scores with coughing (P < 0.05), and significantly lowered supplementary fentanyl requirements (P < 0.05). Groups were similar for sedation, pruritus, nausea, time to ambulation, and satisfaction with analgesia. Clonidine produced a dose-dependent decrease in blood pressure and pulse rate and an increase in vasopressor requirement (P < 0.01). Epidural clonidine infused at 20 microg/h improves analgesia during coughing when combined with epidural bupivacaine-fentanyl in patients undergoing lower abdominal surgery but is associated with hemodynamic changes and increased vasopressor requirement.

PCEA is an attractive concept with special benefits in the obstetric population. It provides a safe and valuable alternative to other approaches to labour analgesia, with demonstrable advantages when used appropriately by motivated women. It also appears to be useful for management of pain after caesarean section. It may occasionally be of benefit in other acute and chronic pain settings in the obstetric population. Despite promising initial results, the full potential of PCEA remains to be explored, and this may be encouraged by ongoing developments in PCA pump technology. Comprehensive comparative studies and large prospective clinical series, further defining its role and safety in various settings, are awaited.

Background: Although meperidine has been used for patient-controlled analgesia both intravenously (PCIA) and epidurally (PCEA), these routes have not been compared, and many studies have suggested that there is no advantage to the epidural route for administration of lipophilic opioids., Methods: A randomized, double-blind, crossover study was conducted for 24 h after cesarean section to compare the analgesic efficacy, side effects, patient satisfaction, drug use, and plasma drug concentrations with meperidine administered either as PCIA or as PCEA. Two groups, stratified for time of cesarean section during epidural anesthesia, postoperatively received either PCEA (group 1) or PCIA (group 2) with identical variables for 12 h before crossing to the other route for an additional 12 h., Results: Results from 45 patients showed a similar speed of analgesic onset but, subsequently, significantly lower pain scores both at rest and with coughing in those receiving PCEA (P = 0.0001). Nausea and pruritus scores did not differ between the groups in the first 12 h postoperatively, but sedation scores were significantly higher with PCIA (P = 0.0001). Patient satisfaction scores and preference significantly favored PCEA (P = 0.0001), with almost 90% of participants preferring the epidural route. Meperidine use was reduced approximately 50% with PCEA (P = 0.0001), and plasma meperidine and normeperidine concentrations were significantly lower (P = 0.0001)., Conclusions: We conclude that after cesarean section, PCEA with meperidine produces high-quality pain relief with few side effects and has significant advantages over PCIA meperidine. With the caveat that neonatal effects in breast-feeding mothers have yet to be evaluated, it can be highly recommended in this population.

Epidural characteristics, when using different solutions for patient controlled epidural analgesia (PCEA), were compared in a randomised, blinded study in labour. Women in group 1 (n=23) self-administered 0.25% plain bupivacaine, in group 2 (n=23) 0.125% plain bupivacaine plus fentanyl 3 microg/ml and in group 3 (n=20) 0.0625% bupivacaine with adrenaline 1:250,000 plus fentanyl 3 microg/ml. There were no significant differences between groups with respect to the quality of obstetric pain relief or maternal satisfaction, the requirement for supplementary boluses of staff-administered solution or the incidence of side effects. There was more intense motor block after 3 hours of PCEA (odds ratio 3.33 for score 0 versus 1, 2 or 3) and a significantly higher ratio of demands received to demands made (P<0.03) in group 1 compared groups 2 and 3. The rate of bupivacaine utilisation was significantly higher in group 1 compared to groups 2 and 3 and lower in group 3 compared to 1 and 2 (median+interquartile range: 16+11-21 vs 9+6-11 vs 4+3-8 mg/hr, P<0.0002). Although all solutions provided effective pain relief for PCEA during labour, the use of a low-dose bupivacaine-fentanyl combination offers clinical advantages and further evaluation of such solutions is warranted.