An open-label randomized controlled clinical trial for comparison of continuous phenylephrine versus norepinephrine infusion in prevention of spinal hypotension during cesarean delivery.

BACKGROUND: During spinal anesthesia for cesarean delivery phenylephrine is the vasopressor of choice but can cause bradycardia. Norepinephrine has both ß- and α-adrenergic activity suitable for maintaining blood pressure with less bradycardia. We hypothesized that norepinephrine would be superior to phenylephrine, requiring fewer rescue bolus interventions to maintain blood pressure. METHODS: Eighty-five parturients having spinal anesthesia for elective cesarean delivery were randomized to Group P (phenylephrine 0.1µg/kg/min) or Group N (norepinephrine 0.05µg/kg/min) fixed-rate infusions. Rescue bolus interventions of phenylephrine 100µg for hypotension, or ephedrine 5mg for bradycardia with hypotension, were given as required to maintain systolic blood pressure. Maternal hemodynamic variables were measured non-invasively. RESULTS: There was no difference between groups in the proportion of patients who required rescue vasopressor boluses (Group P: 65.8% [n=25] vs. Group N: 48.8% [n=21], P=0.12). The proportion of patients who received ⩾1 bolus of phenylephrine was similar between groups (Group P: 52.6% [n=20] vs. Group N: 46.5% [n=20], P=0.58). However, more patients received ⩾1 bolus of ephedrine in the phenylephrine group (Group P: 23.7% [n=9] vs. Group N: 2.3% [n=1], P<0.01). The incidence of emesis was greater in the phenylephrine group (Group P: 26.3% vs. Group P: 16.3%, P<0.001). Hemodynamic parameters including heart rate, the incidence of bradycardia, blood pressure, cardiac output, cardiac index, stroke volume, and systemic vascular resistance and neonatal outcome were similar between groups (all P<0.05). CONCLUSION: Norepinephrine fixed-rate infusion has efficacy for preventing hypotension and can be considered as an alternative to phenylephrine.

Increasing operating room efficiency through electronic medical record analysis.

We used electronic medical record (EMR) analysis to determine errors in operating room (OR) time utilisation. Over a two year period EMR data of 44,503 surgical procedures was analysed for OR duration, on-time, first case, and add-on time performance, within 19 surgical specialties. Maximal OR time utilisation at our institution could have saved over 302,620 min or 5,044 hours of OR efficiency over a two year period. Most specialties (78.95%) had inaccurately scheduled procedure times and therefore used the OR more than their scheduled allotment time. Significant differences occurred between the mean scheduled surgical durations (101.38 ± 87.11 min) and actual durations (108.18 ± 102.27 min; P < 0.001). Significant differences also occurred between the mean scheduled add-on durations (111.4 ± 75.5 min) and the actual add-on scheduled durations (118.6 ± 90.1 minutes; P < 0.001). EMR quality improvement analysis can be used to determine scheduling error and bias, in order to improve efficiency and increase OR time utilisation.

Production and characterization of chitosan/gelatin/ß-TCP scaffolds for improved bone tissue regeneration.

Recently, bone tissue engineering emerged as a viable therapeutic alternative, comprising bone implants and new personalized scaffolds to be used in bone replacement and regeneration. In this study, biocompatible scaffolds were produced by freeze-drying, using different formulations (chitosan, chitosan/gelatin, chitosan/ß-TCP and chitosan/gelatin/ß-TCP) to be used as temporary templates during bone tissue regeneration. Sample characterization was performed through attenuated total reflectance-Fourier transform infrared spectroscopy, X-ray diffraction and energy dispersive spectroscopy analysis. Mechanical characterization and porosity analysis were performed through uniaxial compression test and liquid displacement method, respectively. In vitro studies were also done to evaluate the biomineralization activity and the cytotoxic profile of the scaffolds. Scanning electron and confocal microscopy analysis were used to study cell adhesion and proliferation at the scaffold surface and within their structure. Moreover, the antibacterial activity of the scaffolds was also evaluated through the agar diffusion method. Overall, the results obtained revealed that the produced scaffolds are bioactive and biocompatible, allow cell internalization and show antimicrobial activity against Staphylococcus aureus. Such, make these 3D structures as potential candidates for being used on the bone tissue regeneration, since they promote cell adhesion and proliferation and also prevent biofilm development at their surfaces, which is usually the main cause of implant failure.

The use of thromboelastography for the peripartum management of a patient with platelet storage pool disorder.

We describe the peripartum management of a 26-year-old primigravida with a platelet storage pool disorder who underwent spontaneous vaginal delivery of twins with epidural analgesia. Postpartum hemorrhage from uterine atony, and cervical and vaginal lacerations were treated successfully with 1-desamino-8D-arginine vasopressin and blood products. The use of thromboelastography in the assessment and management of bleeding risk in the setting of platelet storage pool disorder is described.

Ultrasound decreases the failed labor epidural rate in resident trainees.

BACKGROUND: Epidural analgesia is widely used for pain relief during labor. The purpose of this study was to determine if ultrasound measurement of the depth from skin to epidural space before the epidural technique decreases the failure rate of labor analgesia. A secondary objective was to correlate ultrasound depth to the epidural space with actual depth of the needle at placement. METHODS: In this prospective, randomized, non-blinded study, 370 parturients requesting labor epidural analgesia were randomized to receive their epidural technique by first year anesthesia residents with or without prior ultrasound determination of epidural space depth. Outcome variables included the incidence of epidural catheter replacement for failed analgesia and the number of epidural attempts and accidental dural punctures. RESULTS: The ultrasound group had fewer epidural catheter replacements (P<0.02), and epidural placement attempts (P<0.01) compared to the control group. Pearson's correlation coefficients comparing the actual versus ultrasound estimated depth to the epidural space in the longitudinal median and transverse planes were 0.914 and 0.909, respectively. Pearson's correlation coefficient comparing the ultrasound estimated depths to the epidural space in the transverse and longitudinal median planes was 0.940. No significant differences were noted with respect to staff interventions, top-ups, accidental dural punctures, and delivery outcome. CONCLUSIONS: Ultrasound measurement of the epidural space depth before epidural technique placement decreases the rate of epidural catheter replacements for failed labor analgesia, and reduces the number of epidural attempts when performed by first year residents and compared to attempts without ultrasound guidance.

Use of recombinant gp43 isoforms expressed in Pichia pastoris for diagnosis of paracoccidioidomycosis.

gp43 is the main diagnostic antigen for paracoccidioidomycosis (PCM). In vitro, gp43 expression in supernatant fluids of Paracoccidioides brasiliensis cultures can be unstable, and its regulation is poorly understood. We have been able to express soluble recombinant gp43 (gp43r) isoforms as N-mannosylated proteins secreted in the supernatants of Pichia pastoris cultures induced with methanol. They were secreted as major components from day 2 of induction and could be purified with affinity columns containing anti-gp43 monoclonal antibodies. We have expressed P. brasiliensis GP43 (PbGP43) sequences from genotypes A, D, and E, and the correspondent gp43r isoforms (gp43r A, -B, and -C, respectively; 200 ng) were compared to native gp43 in immunodiffusion (ID) and dot blot assays. Among 90 PCM patient sera showing ID-positive reactions with purified native gp43, 100% were positive with gp43rD and gp43rE and 98% reacted with gp43rA. Of these sera, 78 were tested in dot blot assays at a 1:1,000 dilution, and 100% reacted with all recombinant isoforms. In ID assays, the specificity was 100%, since 40 sera from patients with related mycoses and 30 sera from healthy individuals did not react with any of the antigens. In dot blot assays, 100% specificity for PCM occurred when cross-reactive mannose epitopes were neutralized with 10 mM metaperiodate or eliminated through deglycosylation. However, a 1:1,000 serum dilution was already discriminatory for most sera. We suggest that P. pastoris recombinant gp43, especially isoforms D and E, may replace the native antigen in ID and dot blot assays for diagnosis and prognosis of PCM. Regulated expression of large amounts of antigen in nonpathogenic yeast would justify its preferred use.

The incidence of maternal fever during labor is less with intermittent than with continuous epidural analgesia: a randomized controlled trial.

BACKGROUND: This prospective, randomized study was performed to see if intermittent labor epidural analgesia was protective against maternal intrapartum fever, compared to continuous epidural infusion. METHODS: Ninety-two healthy, term, nulliparous women in spontaneous labor were assigned to either intermittent (ILEA) or continuous labor epidural analgesia (CLEA), 46 in each group. In both groups, epidural analgesia was established with fentanyl 100 microg, and 8 mL of either 0.125% bupivacaine with fentanyl 0.0002%, or 0.1% ropivacaine with fentanyl 0.0002%. Maintenance in the CLEA group was with the same bupivacaine/fentanyl or ropivacaine/fentanyl solutions at 10-15 mL/h. In the ILEA group, additional boluses of the same solution were given as needed. Maternal tympanic temperature was measured before epidural insertion, 4-hourly during labor and 4 h post partum. Fever was defined as a temperature of > or =38 degrees C. Newborn temperature was noted within 60 min of birth. RESULTS: The incidence of fever in ILEA was significantly lower at four hours (2/42, vs. 10/44 in CLEA, P=0.036). No significant differences were detected at other time periods. Mean maternal temperatures did not differ between groups at any time. There were no differences in neonatal temperature or neonatal sepsis evaluation rate (CLEA vs. ILEA 0/46 vs. 2/43, P=0.45). CONCLUSIONS: Intermittent epidural injections appear to protect against intrapartum fever in the first 4 hours of labor analgesia, compared to continuous infusion. This may be due to intermittent partial recovery of heat loss mechanisms between injections. Neonatal sepsis evaluation rates were similar in the two groups.

A parturient with neurofibromatosis type 2: anesthetic and obstetric considerations for delivery.

Neurofibromatosis type 2 is an extremely rare form of neurofibromatosis characterized by central nervous system involvement with bilateral vestibular schwannomas and spinal tumors. Anesthetic management of a parturient with neurofibromatosis type 2 has not been fully reported, and the condition is challenging to obstetric anesthesiologists due to the presence of intracranial and intraspinal canal neurofibromas. We present a case of neurofibromatosis type 2 referred for delivery. Because of central neuraxial involvement, regional anesthesia was avoided, and the patient delivered by cesarean section under general anesthesia. The importance of pre-operative diagnosis and multidisciplinary management for neurofibromatosis type 2 is emphasized and anesthetic and obstetric considerations for delivery are presented.

The immune system in the oxidative stress conditions of aging and hypertension: favorable effects of antioxidants and physical exercise.

Several studies have shown that both oxidative stress and inflammation are linked to the process of hypertension and that the immune system is also involved in this age-related process. More specifically, the oxygen stress related to immune system dysfunction seems to have a key role in senescence, in agreement with the oxidation/ inflammation theory of aging. From a practical point of view, and according to our own research, the immune functions change in a similar fashion in hypertension and aging. As antioxidant diet supplementation decreases oxidative stress, it may be useful to treat hypertension and increase longevity. Probably, these favorable effects are mediated by an antioxidant-induced improvement of the immune function. The practice of moderate physical exercise shows similar favorable effects, and indeed our studies on exercising hypertensive women demonstrate an improved immune function, probably linked to raised levels of intracellular antioxidant defenses. The present review summarizes a selection of data related to the above from other authors as well as some findings from our own work.

Failed regional anesthesia with reduced spinal bupivacaine dosage in a parturient with achondroplasia presenting for urgent cesarean section.

A 36-year-old patient with a history of previous back surgery, asthma, latex allergy and achondroplasia presented for urgent cesarean delivery at 31 weeks' gestation for worsening nonimmune fetal hydrops. The fetus was diagnosed with trisomy 21 and achondroplasia. Because of the urgent clinical situation, the patient was given a spinal anesthetic, which required supplemental intravenous sedation after delivery of the fetus. This case report discusses the controversies in anesthetic management of this complicated patient and compromised fetus regarding general anesthesia, epidural, spinal and combined spinal-epidural anesthesia.

Chorioamnionitis, not epidural analgesia, is associated with maternal fever during labour.

PURPOSE: Maternal fever is associated with chorioamnionitis and has been linked to labour epidural analgesia (LEA). The purpose of this study was to determine possible associations between LEA and chorioamnionitis, maternal fever, operative delivery rate, and neonatal outcome. METHODS: Data from 14,073 patients were entered into a database over a two-year period. From this database, 62 nulliparous parturients with clinical chorioamnionitis (amnionitis), but without LEA were identified (Group I). Two other groups who received LEA were matched for parity and gestation: Group II - LEA with concomitant amnionitis (n=50) and, Group III - LEA without concomitant amnionitis (n=201). The diagnosis of chorioamnionitis was confirmed by histologic examination. Results are expressed as mean +/- SD and analyzed at P <0.05 using ANOVA or Chi-square. RESULTS: No differences were noted among the groups in the operative delivery rate or Apgar scores at five minutes. The percentage of patients with maternal fever during labour (38.0 degrees C) with amnionitis was significantly less in Group III compared to the other groups (100% in both Groups I and II vs 1.0% in Group III; P=0.000). Likewise, Group III had a lower percentage of neonates with Apgar scores <7 at one minute (35.5% in Group I, 20.0% in Group II, 17.4% in Group III; P=0.010). The percentage of histologic chorioamnionitis was significantly higher in both amnionitis groups compared to Group III (67.7% in Group I, 56.0% in Group II, 4.0% in Group III; P=0.000). CONCLUSION: LEA without chorioamnionitis is not associated with maternal fever (38.0 degrees C), increased operative delivery rates or low Apgar scores.

Effect of epidural analgesia with ambulation on labor duration.

BACKGROUND: Ambulatory epidural analgesia (AEA) is a popular choice for labor analgesia because ambulation reportedly increases maternal comfort, increases the intensity of uterine contractions, avoids inferior vena cava compression, facilitates fetal head descent, and relaxes the pelvic musculature, all of which can shorten labor. However, the preponderance of evidence suggests that ambulation during labor is not associated with these benefits. The purpose of this study is to determine whether ambulation with AEA decreases labor duration from the time of epidural insertion to complete cervical dilatation. METHODS: In this prospective, randomized study, 160 nulliparous women with AFA were randomly assigned to one of two groups: AEA with ambulation and AEA without ambulation. AEA blocks were initiated with 15-20 ml ropivacaine (0.07%) plus 100 microg fentanyl, followed by a continuous infusion of 0.07% ropivacaine plus 2 microg/ml fentanyl at 15-20 ml/h. Maternal measured variables included ambulation time, time from epidural insertion to complete dilatation, stage II duration, pain Visual Analogue Scale scores, and mode of delivery. APGAR scores were recorded at 1 and 5 min. Results are expressed as mean +/- SD or median and analyzed using the t test, chi-square, or the Mann-Whitney test at P < or = 0.05. RESULTS: The ambulatory group walked 25.0 +/- 23.3 min, sat upright 40.3 +/- 29.7 min, or both. Time from epidural insertion to complete dilatation was 240.9 +/- 146.1 min in the ambulatory group and 211.9 +/- 133.9 min in the nonambulatory group (P = 0.206). CONCLUSION: Ambulatory epidural analgesia with walking or sitting does not shorten labor duration from the time of epidural insertion to complete cervical dilatation.

Evolution of ellagitannins in Spanish, French, and American oak woods during natural seasoning and toasting.

The evolution of tannins in Spanish oak heartwood of Quercus robur L., Quercus petraea Liebl.,Quercus pyrenaica Wild., and Quercus faginea Lam. was studied in relation to the processing of wood in barrel cooperage. Their evolution was compared with that of French oak of Q. robur (Limousin, France) and Q. petraea (Allier, France) and American oak of Quercus alba L. (Missouri), which are habitually used in cooperage. Two stages of process were researched: the seasoning of woods during 3 years in natural conditions and toasting. Total phenol and total ellagitannin contents and optical density at 420 nm of wood extracts were determined. The ellagitannins roburins A-E, grandinin, vescalagin, and castalagin were identified and quantified by HPLC, and the molecular weight distribution of ellagitannins was calculated by GPC. During the seasoning process the different ellagitannin concentrations decreased according to the duration of this process and in the same way as those in French and American woods. The toasting process also had an important influence on the ellagitannin composition of wood. Roburins A-E, grandinin, vescalagin, and castalagin decreased during this process in the Spanish wood species, in the same proportion as in the French and American ones. Also, the seasoning and toasting processes lead to qualitative variations in the structure of ellagitannins, especially in the molecular weight distribution, as was evidenced by GPC analysis of their acetylated derivatives.

Changes in low molecular weight phenolic compounds in Spanish, French, and American oak woods during natural seasoning and toasting.

The evolution of low molecular weight polyphenols in Spanish oak heartwood of Quercus robur,Quercus petraea, Quercus pyrenaica, and Quercus faginea was studied by HPLC, in relation to the processing of wood in barrel cooperage. The polyphenolic composition of Spanish woods subjected to natural seasoning for 3 years and to the toasting process was studied in relation to those of French oak of Q. robur (Limousin) and Q. petraea (Allier) and American oak of Q. alba (Missouri), which are habitually used in cooperage. The concentrations of benzoic and cinnamic acids and aldehydes of Spanish woods increased during seasoning depending on the duration of this process and in the same way as those of French and American woods. The process having the main influence on the phenolic composition of wood was the toasting. It led to high increases in the concentration of phenolic aldehydes and acids, especially cinnamic aldehydes (sinapic and coniferylic aldehydes), followed by benzoic aldehydes (syringaldehyde and vanillin) and benzoic acids (syringic and vanillic acids). This polyphenolic composition in Spanish oak species evolved during toasting as in French and American oak, but quantitative differences were found, which were especially important in American species with respect to the others.

Postdural puncture headache: a randomized comparison of five spinal needles in obstetric patients.

This prospective, blinded, randomized study compares the incidence of postdural puncture headache (PDPH) and the epidural blood patch (EBP) rate for five spinal needles when used in obstetric patients. One thousand two women undergoing elective cesarean delivery under spinal anesthesia were recruited. We used two cutting needles: 26-gauge Atraucan and 25-gauge Quincke, and three pencil-point needles: 24-gauge Gertie Marx (GM), 24-gauge Sprotte, and 25-gauge Whitacre. The needle for each weekday was chosen randomly. Cutting needles were inserted parallel to the dural fibers. The incidences of PDPH were, respectively, 5%, 8.7%, 4%, 2.8%, and 3.1% for Atraucan, Quincke, GM, Sprotte, and Whitacre needles (P = 0.04, chi(2) analysis), and the corresponding EBP rates in those with PDPH were 55%, 66%, 12.5%, 0%, and 0% (P = 0.000). The Quincke needle had a more frequent PDPH rate than the Sprotte or the Whitacre needle (P = 0.02) and a more frequent EBP rate than the GM, Sprotte, or the Whitacre needle (P = 0.01). The Atraucan needle had a more frequent EBP rate than the Sprotte or Whitacre needle (P = 0.05). Neither the PDPH rate nor the EBP rates differed among the pencil-point needles. The cost of EBP must be taken into consideration when choosing a spinal needle. We conclude that pencil-point spinal needles should be used for subarachnoid anesthesia in obstetric patients.

Improved bowel function after gynecological surgery with epidural bupivacaine-fentanyl than bupivacaine-morphine infusion.

PURPOSE: To compare postoperative gastrointestinal recovery between continuous epidural bupivacaine-fentanyl and bupivacaine-morphine. METHODS: In a blinded, randomized, prospective trial, 60 women undergoing surgery for gynecologic cancer were studied. Anesthesia was provided by a combined general/epidural (L2-3 catheter) technique without epidural opioids. Postoperative epidural analgesia was by continuous infusion of bupivacaine 0.1% with either morphine 0.05 mg x ml(-1) (BM) or fentanyl 5 microg x ml(-1) (BF). Visual Analogue Scale (VAS) scores for pain at rest and during movement, and the return of bowel function were collected for three days and the duration of hospitalization were noted. RESULTS: On POD-1, 18.5% of patients in the BM group had emesis compared with none in the BF group (P = 0.038) and fewer patients in the BM group tolerated clear oral fluids (11.1% BM vs 40.6% BF, P = 0.025). These differences became insignificant on POD-2 and 3. Median pain scores were comparable at rest and ranged from 10-20 in the BM group vs 0-20 in the BF group over the three days. Similarly, median pain scores with movement respectively ranged from 20-25 and 20-30 in the BF and BM groups. The mean duration of hospitalization was longer in the BM group (5.7 +/- 2.4) vs BF (4.5 +/- 1.2 days), P = 0.017. CONCLUSION: Epidural BM and BF provided equally effective postoperative analgesia at rest and during movement. Compared with BM, epidural BF is associated with less emesis and an increased ability to tolerate oral fluids on POD-1 and an overall shorter hospital stay.

Uniport soft-tip, open-ended catheters versus multiport firm-tipped close-ended catheters for epidural labor analgesia: a quality assurance study.

STUDY OBJECTIVE: To compare a multiport, firm-tipped, close-ended, epidural catheter (Portex catheter) with a uniport, open-ended, soft-tipped, wire-reinforced catheter (Arrow catheter) in obstetric patients. STUDY DESIGN: Prospective data collection for intradepartmental quality assurance. SETTING: Obstetric unit in a tertiary care maternity hospital. PATIENTS: 2612 patients requesting labor analgesia. INTERVENTIONS: The Arrow catheter was used in 1,352 women and the Portex catheter in 1,260 women. MEASUREMENTS AND MAIN RESULTS: The incidence of unsatisfactory block were 3.3% and 4.4% with the Arrow and Portex catheters, respectively (p = 0.2). The catheter perforated the dura matter in 0.4% of cases with both catheters. The incidence of epidural venipuncture was 1.1% with the Arrow catheter and 5.7% with the Portex catheter (p = 0.0001). Paresthesias occurred in 6% of cases with the Arrow catheter and 11. 2 % of cases with the Portex catheter (p = 0.0001). Epidural catheter reinsertion was required in fewer patients in the Arrow group than in the Portex group (4.8% vs. 7.1%; p = 0.01). CONCLUSIONS: In obstetric patients, the softer uniport Arrow catheter produces paresthesias and venipunctures less frequently than the firm multiport Portex catheter.