Anesthetic management of a patient with type 1 neurofibromatosis and an occult pheochromocytoma: a case report.

Neurofibromatosis type 1 is a complex genetic disorder affecting multiple organ systems. Cardiovascular manifestations include hypertension, often associated with concomitant pheochromocytoma. We present a hypertensive crisis during induction of anesthesia in a patient with neurofibromatosis type 1, scheduled for abdominal myomectomy, which revealed an undiagnosed pheochromocytoma. The case highlights the importance of assessing all patients with neurofibromatosis type 1 for pheochromocytoma, because if it is left undiagnosed, it can be disastrous in the setting of anesthesia and surgery.

Anesthetic management of a patient with type 1 neurofibromatosis and an occult pheochromocytoma: a case report

Abstract Neurofibromatosis type 1 is a complex genetic disorder affecting multiple organ systems. Cardiovascular manifestations include hypertension, often associated with concomitant pheochromocytoma. We present a hypertensive crisis during induction of anesthesia in a patient with neurofibromatosis type 1, scheduled for abdominal myomectomy, which revealed an undiagnosed pheochromocytoma. The case highlights the importance of assessing all patients with neurofibromatosis type 1 for pheochromocytoma, because if it is left undiagnosed, it can be disastrous in the setting of anesthesia and surgery.

Major depressive disorder (MDD), antidepressants, and uncontrolled hypertension: A report of intraoperative autonomic dysregulation.

Objective: Major depressive disorder (MDD) represents the leading cause of mental disability worldwide. While relations between MDD and alterations to the cardiovascular system have been studied before, the autonomic dysfunction caused by the disease and the medical therapies involved during treatment has not been widely reported. Our case aims to prove such linkage exists and is a potent hazard during major operative procedures. Methods: Studies have associated the disorder with a concomitant dysfunction of the autonomic nervous system, predisposing patients to hypertension. We present the case of a patient presenting with an intraoperative hypertensive spike that could be attributed to such a dysregulation of the autonomic system, in the absence of any other possible explanation. Results: The observed intraoperative hypertensive spike was managed pharmacologically, and the patient did not experience any further hemodynamic instability or postoperative complications. Conclusion: Our case tries to highlight a disregarded aspect of perioperative management for patients suffering from MDD.

Currarino Syndrome: A Rare Case Report of Sepsis and Its Management.

Currarino syndrome (CS) is characterized by a triad of anomalies consisting of: a sacral bone defect, anorectal malformations and a pre-sacral mass. We present the case of an adult patient with a medical history of CS who presented with septic shock and was subjected to an emergency laparotomy due to severe abdominal distension. In this particular case, we underline the importance of immediate surgery on the patient's outcome as well as the considerable role of landiolol in controlling the heart rate with no further deterioration of blood pressure in this patient presenting with atrial fibrillation and sepsis.

Acute and Chronic Pain after Cesarean Delivery under Subarachnoid Anaesthesia. Is Postoperative Analgesia Adequate? A Cohort Observational Study.

Objectives: Uncontrolled pain after cesarean delivery is associated with women's dissatisfaction and limited ability to take care of the neonate. Materials and methods:This prospective observational study included 173 women scheduled for elective cesarean delivery under spinal anesthesia. Postoperative analgesia included subcutaneous morphine 0.1 mg/kg in the post-anesthesia care unit, followed by intravenous paracetamol 1000 mg every eight hours and intravenous diclofenac 75 mg every 12 hours in the ward. Subcutaneous morphine was repeated on demand. Pain intensity at rest, pain intensity after movement and cumulative morphine consumption were recorded at 2, 4, 8, and 24 hours postoperatively. Acute pain intensity was assessed on a 100 mm visual analogue scale (VAS, score 0-100 mm). Three and six months postoperatively, women were interviewed by phone for the presence of persisting pain, abnormal sensation in the wound area and analgesic consumption. Results:Our results showed that 24 hours postoperatively the mean dose of morphine was 16±7.1 mg and VAS scores at rest and after movement were 23±17.3 mm and 40±20.9 mm, respectively. The mean VAS scores at rest remained below 31 mm at all times, while after movement they were over 40 mm at both four and eight hours postoperatively (45±23.8 mm and 43±23.2 mm, respectively). Three months postoperatively, 15% of women reported the presence of continuous or intermittent pain, 72% loss of sensation or numbness at the site of surgery and 32% occasional analgesic consumption at home. Six months after surgery, 5% of women reported pain, 44% loss of sensation or numbness in the wound area and none of them (0%) consumed analgesics due to persistent post-cesarean delivery pain. Conclusion:Based on the above-mentioned findings, we concluded that the amount of morphine consumed in the ward was low and possibly inadequate to alleviate early post-cesarean delivery pain. The overall incidence of persisting pain was low and consistent with previous studies.

Measurements of oxygen saturation of brain, liver and heart areas in the supine and sitting position using near infrared spectrophotometry.

BACKGROUND AND AIMS: Regional oxygen saturation (rSO2) monitoring of the brain by near-infrared spectroscopy (NIRS) has been mainly used during carotid endarterectomy. The present study was conducted in volunteers and investigates the rSO2 values of the brain, heart and liver tissue as assessed by NIRS in the supine and the sitting position. METHODS: After obtaining written informed consent from forty-nine healthy volunteers, rSO2 values were recorded in the heart and liver areas in the supine and the sitting position, while simultaneously the rSO2 values of the brain. RESULTS: The rSO2 brain values in the supine and the sitting position were 69 ± 6.0 and 66 ± 6.1 respectively (p = 0.0001). The rSO2 values in the supine and the sitting position were 76 ± 10.5 and 79 ± 6.7 for the heart (p > 0.05) and 85 ± 6.8 and 82 ± 7.2 for the liver, (p = 0.007). Heart rSO2 values were higher than the brain rSO2 values in both the supine (76 ± 10.4 versus 69 ± 6.6; p = 0.0001) and the sitting position (79 ± 6.7 versus 66 ± 6.1; p = 0.0001). The liver rSO2 values were also higher than the brain rSO2 values in the supine (85 ± 6.8 versus 69 ± 6.0; p = 0.0001) and in the sitting position (82 ± 7.2 versus 66 ± 5.7; p = 0.0001). Arterial blood pressure and arterial oxygen saturation (SpO2) did not differ between the two positions but the heart rate was higher in the sitting position (p = 0.030). CONCLUSIONS: We conclude that brain and liver (but not heart) rSO2 values are higher in the supine than sitting position. Additionally, NIRS may be used to assess oxygenation of the heart and liver.

Epidural fentanyl does not affect cervical dilation and progress of first stage of vaginal delivery: a randomized, double-blind study.

OBJECTIVE: Local anesthetics combined with opioids are commonly used in labor epidural analgesic schemes. This study investigated if the addition of fentanyl to epidural ropivacaine can affect cervical dilation and progress of vaginal delivery. METHODS: Sixty-two nulliparous parturients were randomized to receive epidurally 8 ml ropivacaine 0.2% combined with fentanyl 20 µg (F/R-group, n = 31) or with normal saline 0.4 ml (R-group, n = 31), every hour. Rescue doses of 5 ml ropivacaine 0.2% were also administered. Measurements were performed every 60 min until full cervical dilation. The primary end-point was the time to reach 10-cm cervical dilation. Secondary outcomes were Bishop scores, mode of delivery, total ropivacaine dose, pain, and satisfaction scores (numerical scale, 0-10). RESULTS: Data from 60 parturients (29 in the F/R and 31 in the R-group) were analyzed. The F/R-group had 26 vaginal deliveries (four instrumentally assisted), and three cesarean deliveries. The R-group had 27 vaginal deliveries (six instrumentally assisted) and 4 cesarean deliveries. Time to 10-cm cervical dilation did not differ between the groups (4 ± 2.4 h in the F/R-group vs 4.4 ± 2.1 h in the R-group, p = .341). The number of women remaining in the study every hour until full cervical dilation and Bishop scores for a 4-h period did not differ between the groups (p = .617). Total ropivacaine dose was comparable between the groups, but the F/R-group reported significantly lower pain (p = .01) and higher satisfaction scores (p = .001). CONCLUSIONS: The addition of fentanyl to ropivacaine 0.2% solution did not affect cervical dilation and progress of the first stage of labor, but improved both analgesia and satisfaction.

Parotid Gland Lipoma: An Unusual Entity.

The occurrence of lipomas in the parotid gland is extremely rare, and impossible to differentiate clinically. A case of this bizarre entity is reported herein, which was treated successfully with superficial parotidectomy. A 57-year-old man with a well-circumscribed, rubbery mass, probably arising from the right parotid gland was investigated in our hospital initially with ultrasound scan, and finally with MRI-scan. Both imaging modalities implied a benign lipomatous tumor and the patient underwent an uneventful superficial parotidectomy. Although adipose tissue is a natural component of parotid glands, lipomas arising in the gland are very unusual. The entity'™s incidence is about 1% (0.6-4.4%) of parotid gland mass lesions and history of previous trauma in the area is the most common pathophysiological mechanism described. Tomographic imaging modalities are very accurate in preoperative diagnosis and cosmetic appearance is the usual indication for surgical intervention. Any particular symptoms jeopardize clinically the diagnosis of parotid lipoma. As always, surgical excision should respect the facial nerve and branches.

Polymorphisms in prothrombotic genes in young stroke patients in Greece: a case-controlled study.

Mechanisms of ischemic stroke in young adults are poorly understood. The aim of the study was to investigate and compare the frequency of common variations in prothrombotic genes between young patients with ischemic stroke and controls. Fifty-one cases of first-ever ischemic stroke and 70 community-based controls aged below 50 years were studied. In both groups, the insertion/deletion 4G/5G variation (-675 4G/5G PAI-1) as well as the single-nucleotide polymorphism-844 G/A of the PAI-1 (-844 G/A PAI-1) gene promoter, factor V Leiden (FVL) G1691Α, the prothrombin variant (allele 20210A, FIIG20210A), factor XIII-A Val34Leu polymorphism (FXIII-AVal34Leu) and C677T methylenotetrahydrofolate reductase (C677T MTHFR) polymorphism have been assessed. The -675 4G/5G PAI-1 allele distribution differed significantly between patients and controls (P = 0.020), but no difference was found regarding the distribution of -844 G/A PAI-1 (P = 0.493), FVL (P = 0.199), FIIG20210A (P = 0.410), FXIII-AVal34leu (P = 0.160) and C677T MTHFR (P = 0.788). A lower frequency of 5G/5G genotype and a higher frequency of the 4G/5G genotype of the PAI -675 4G/5G polymorphism was found in young ischemic stroke patients compared to healthy controls. Further epidemiological studies are needed to investigate the differences between different geographic areas, and prospective cohort studies are needed to investigate the possible protective role of 5G/5G polymorphism.

Cesarean delivery under spinal anesthesia is associated with decreases in cerebral oxygen saturation as assessed by NIRS: an observational study.

OBJECTIVES: To investigate the effect of spinal anesthesia on cerebral rSO2 during elective cesarean delivery (CD). METHODS: Thirty-four women scheduled for elective CD under spinal anesthesia were recruited. In the operating room rSO2 of the left and right frontal area and right thigh was recorded using three disposable sensors. A combination of 1.8-2.0 ml of 0.75% ropivacaine plus 10 µg of fentanyl were injected intrathecally. Systolic and diastolic blood pressure, heart rate, SpO2 as well as rSO2 of the left and right forehead areas and right thigh were recorded before, 5, 10, and 25 to 50 minutes after spinal injection, after uterine incision and placenta delivery, and analyzed with ANOVA repeated measures. The study was approved by the Aretaieio Hospital Institutional Review Board and registered with ClinicalTrials.gov (ID: NCT01669135). RESULTS: The rSO2 left and right frontal area values decreased significantly from baseline (p=0.0001 and p=0.0001 respectively), with most remarkable decreases 5 and 10 minutes after spinal injection, from 65 (SD 8.7)% to 56 (SD 9.3)% and 56 (SD 9.5)% (p=0.0001 and p=0.0001) for the left and from 63 (SD 7.7)% to 55 (SD 9.3)% and 56 (SD 8.9)% (p=0,0001 and p=0.0001) for the right frontal area respectively. The rSO2 right thigh values increased significantly during the study period (p=0.0001). KEY LIMITATIONS: Contribution of extracranial circulation to the rSO2, lack of PaCO2 and cardiac output measurements. CONCLUSIONS: Women undergoing CD under spinal anesthesia may present decreases in cerebral rSO2. The clinical impact of these results remains to be determined.

Intravenous lidocaine does not affect the anesthetic depth during rapid sequence induction and intubation as assessed by Bispectral Index monitoring: a randomized double blind study.

INTRODUCTION: We investigated the impact of intravenous lidocaine on anesthetic depth, as assessed by Bispectral Index score (BIS), and hemodynamic responses to rapid sequence induction/intubation. MATERIAL AND METHODS: Eighty-four surgical patients with risk factors for regurgitation/aspiration were randomized to receive either lidocaine 1.5 mg/kg or normal saline in a double-blind fashion. Propofol 2 mg/kg, lidocaine or normal saline, followed by rocuronium 1 mg/kg were administered intravenously and trachea was intubated under cricoid pressure application. The BIS scores were recorded before induction of anesthesia, immediately after, at 30 s and 1 min after rocuronium injection and every 30 s after intubation, for 10 min. Systolic/diastolic blood pressure and heart rate were measured before induction, immediately after and at 1 min following rocuronium administration, and every minute for 10 min after intubation. RESULTS: Data from 78 patients were analyzed. Demograpic characteristics did not differ between the study groups. A total of 24 BIS scores were recorded for each patient. No difference was found in BIS values between lidocaine and control groups at any time point (F = 2.936, p = 0.91). Also no difference was detected in heart rate, systolic and diastolic blood pressure at any time point of the study period between the two groups (F = 0.063, p = 0.80, F = 0.007, p = 0.93, F = 0.435, p = 0.51 respectively). No episodes of significant bradycardia occurred and none of the patients reported awareness/recall of the procedure. CONCLUSIONS: Lidocaine 1.5 mg/kg given intravenously during rapid sequence induction does not affect BIS values, or blunt the hemodymanic response to laryngoscopy and intubation.

The impact of 30 ml/kg hydroxyethyl starch 130/0.4 vs hydroxyethyl starch 130/0.42 on coagulation in patients undergoing abdominal surgery.

BACKGROUND & OBJECTIVES: Hydroxyethyl starches (HES) 130/0.4 (Voluven;) and 130/0.42 (Venofundin;) impair coagulation less than older HES solutions with higher molecular weight and molar substitution. Thus, these may be used in high doses up to 50 ml/kg/day. The aim of this study was to investigate and compare the effects of HES 130/0.4 versus HES 130/0.42 on coagulation after the intraoperative infusion of 30 ml/kg in patients undergoing major abdominal surgery. METHODS: Fifty two patients scheduled for elective major abdominal surgery were randomized to receive 30 ml/kg of HES 130/0.4 or HES 130/0.42 intraoperatively. Coagulation variables were assessed before and after infusion of the colloid solution using thrombelastography. RESULTS: Data from 49 patients, 25 patients in the HES 130/0.4 and 24 in the HES 130/0.42 group, were analyzed. Measurements of reaction time, kinetic time, α-angle, maximum amplitude and coagulation index before and after colloid infusion did not differ between the groups. Within each group, after colloid infusion, reaction time did not change significantly, while α-angle, maximum amplitude and coagulation index values were significantly decreased (P <0.01, P<0.001 and P<0.001, respectively in HES 130/0.4 group and P<0.01, P<0.001 and P<0.01, respectively in HES 130/0.42 group). Kinetic time was significantly increased (P<0.001) in both the groups. In both groups, all thrombelastographic measurements after colloid infusion were found within normal limits. INTERPRETATION & CONCLUSIONS: HES 130/0.4 and HES 130/0.42 showed similar, not clinically significant effects on coagulation, as assessed by thrombelastography, when a dose of 30 ml/kg was administered in patients undergoing major abdominal surgery.

Postoperative analgesic requirements after subarachnoid or epidural anesthesia with ropivacaine 0.75% in cesarean section. A double-blind randomized trial.

OBJECTIVE: Postoperative analgesic requirements and pain scores were compared after subarachnoid versus epidural anesthesia with plain ropivacaine 0.75% for elective cesarean section. STUDY DESIGN: Ropivacaine 0.75% was randomly administered for subarachnoid or epidural anesthesia in 108 parturients, scheduled for cesarean section. Times for the sensory block to reach T4 level and to regress to T6 level were recorded. At 2, 4, 8 and 24 h postoperatively, pain scores at rest and cough, morphine consumption as well as patient satisfaction, incidence of headache, nausea and/or vomiting were measured. RESULTS: Median (min-max) time for the sensory block to reach T4 was 7 (3-0) min versus 24 (16-73) min and to regress to T6 was 126 (70-332) min versus 200 (98-439) min in the subarachnoid and epidural groups, respectively (p=0.001). Although the subarachnoid had more analgesic consumption than the epidural group at 2 and 4 h postoperatively (7.3±4.7 vs. 1.8±2.4 mg, p=0.001 and 9±5.7 vs. 3.3±3.8 mg, p=0.001, respectively) no difference was observed at 8 or 24 h postoperatively (p=0.14 and p=0.38, respectively). VAS scores at rest and after cough (p=0.56, p=0.35, respectively), patient satisfaction (p=0.61), incidence of headache (p=1.0), nausea and/or vomiting (p=0.78) did not differ between the two groups. CONCLUSIONS: Postoperative pain, analgesic requirements, patient satisfaction and adverse effects did not differ when subarachnoid or epidural anesthesia with ropivacaine 0.75% was used for elective cesarean section. Nevertheless, subarachnoid provides faster onset and offset of the block, compared to epidural anesthesia. The key limitation of this study is the lack of postoperative serum ropivacaine measurements taken with concurrent pain score measurements.

Perioperative pregabalin for acute and chronic pain after abdominal hysterectomy or myomectomy: a randomised controlled trial.

CONTEXT: The antiepileptics gabapentin and pregabalin are used as adjuvants to control postoperative pain. OBJECTIVE: The aim of the present study was to investigate the effect of perioperative administration of pregabalin on postoperative acute and chronic pain and analgesic requirements. SETTING: Department of Anaesthesiology, Aretaieio University Hospital, Athens, Greece. PATIENTS: Eighty patients scheduled for abdominal hysterectomy or myomectomy were randomly assigned to the pregabalin or to the control group. INTERVENTION: The pregabalin group received 150 mg of pregabalin 8-hourly, starting on the afternoon before surgery and continued until the fifth postoperative day. The control group was similarly treated, but received placebo capsules instead. MEASUREMENTS: Postoperative intravenous morphine and Lonalgal (30 mg codeine with 500 mg paracetamol) tablet consumption, visual analogue pain scores at rest and on coughing, sedation, anxiety, dizziness, ataxia, blurred vision and diplopia were recorded. One and 3 months postoperatively patients were interviewed for the presence of pain and analgesic needs due to surgery. RESULTS: The pregabalin-treated patients consumed less morphine during the first 48 h postoperatively (P = 0.0001). However, consumption of Lonalgal tablets and visual analogue scores for pain at rest and on coughing did not differ between the groups. No difference was found in sedation and anxiety scores between the patients who received placebo or pregabalin. Patients in the control group had lower incidences of dizziness (29 versus 58%, P = 0.015), ataxia (0 versus 18%, P = 0.011), blurred vision (6 versus 26%, P = 0.028) and diplopia (0 versus 16%, P = 0.023). Presence of pain, analgesic intake due to surgery and decreased or absent sensation around the wound did not differ between the groups 1 and 3 months postoperatively. CONCLUSION: Pregabalin in the doses given decreased morphine requirements for the first 48 h postoperatively, but neither altered the analgesic requirements beyond 48 h nor had any effect on acute, late or chronic pain.

An assessment of subarachnoid block: a survey of 175 articles and recommendations for improvement.

BACKGROUND: Assessment of subarachnoid block, particularly the sensory component, may be incomplete and influence the conclusions of studies involving subarachnoid anesthesia, as well as their application in routine clinical practice. METHODS: We manually searched 175 articles concerning subarachnoid block published from 2006 to 2009 in 8 anesthesia journals to determine the components of the subarachnoid anesthetic procedure recorded as well as the extent of sympathetic and motor block. RESULTS: The level of subarachnoid injection was reported in 86% of the articles, baricity in 84%, concentration of local anesthetic in 77%, patient's position in 75%, needle size in 77%, and needle type in 71%. The stimulus used for assessing sensory block was reported in 69% of the articles; 17% described the block as unilateral or bilateral, and 11% described the lines along which the stimulus was applied. Motor and sympathetic block were assessed in 40% and 18% of studies, respectively. CONCLUSIONS: These results suggest incomplete description of tools and assessment of sensory block in studies involving subarachnoid anesthesia. We propose a checklist to facilitate a more standardized evaluation of the extent of subarachnoid anesthesia.

Impact of graded hypothermia on coagulation and fibrinolysis.

BACKGROUND: Hypothermia has a detrimental effect on hemostatic mechanism. The purpose of this experimental study was to investigate the effect of graded hypothermia on markers of the anticoagulant system (antithrombin III and protein C) and fibrinolytic system (plasminogen, α(2)-antiplasmin), and on vascular wall and other tissue specimens. MATERIALS AND METHODS: Ten New Zealand rabbits were subjected to mild and then moderate core hypothermia of 32 °C for 60 min. Blood samples were obtained at normothermic (T(1)), mild (T(2)), and moderate (T(3)) hypothermic conditions. Chromogenic assay methods were used to determine quantitatively (%) the activity of antithrombin III, protein C, plasminogen, and α(2)-antiplasmin. Hypothermic values were compared with the normothermic values. Tissue and vessel wall specimens were examined under light microscope. RESULTS: Reduction of activity (%) from normothermia (T(1)) to mild (T(2)) and moderate (T(3)) hypothermia was found for antithrombin III (103.40 ± 12.54, 87.40 ± 13.50, and 82.70 ± 20.78, respectively, with statistically significant difference between T(1)-T(3): P = 0.03), for protein C (70.1 ± 7.51, 56.30 ± 8.34, and 53.1 ± 7.34, with statistically significant difference between T(1)-T(2) and T(1)-T(3): P = 0.015 for both comparisons) and α(2)-antiplasmin (97 ± 9.63, 80.60 ± 11.73, and 83.70 ± 13.94, with statistically significant difference between T(1)-T(2): P = 0.006). Plasminogen activity was increased (14.50 ± 0.52, 16.30 ± 1.63, and 17.30 ± 2.45, with statistically significant difference between T(1)-T(2) and T(1)-T(3): P = 0.033 for both comparisons). Histologic examination revealed no significant lesions on tissue and vessel wall specimens. CONCLUSIONS: The results of our study suggest that even though the hypothermia period was relatively short, the processes of coagulation and fibrinolysis were altered with simultaneous changes.

Association between factors predicting and assessing the airway and use of intubating laryngeal mask airway.

BACKGROUND AND OBJECTIVE: The Intubating Laryngeal Mask Airway FastrachTM (ILMA) has been used with success in difficult intubation cases. The purpose of this study is to evaluate the effect of mouth opening, Mallampati classification, thyromental distance and Cormack-Lehane Grade, on the ease of ILMA use. METHODS: Eighty one patients ASA I-II, were assessed preoperatively for mouth opening, Mallampati classification and thyromental distance. After induction with propofol and rocuronium, the first investigator recorded Cormack-Lehane Grade by direct laryngoscopy. Subsequently an appropriate size ILMAwas inserted by the second investigator and correct placement was confirmed by adequate ventilation and normal capnogram. A maximum of three ILMA insertion attempts were allowed and the number was recorded. Then blind intubation was attempted and classified as follows, according to Intubation Difficulty Grade (IDG): IDG-1: intubation succeeded: at first attempt requiring no or minor ILMA manipulations. IDG-2: intubation succeeded at second attempt requiring major ILMA manipulations or size change. IDG-3: intubation failed after the second attempt or oesophageal intubation occurred at either attempt. In failure of the technique direct laryngoscopy was the alternative approach. RESULTS: Success rates in insertion of ILMA and in blind intubation were 100% and 92.6% respectively. No difference was found between Cormack-Lehane Grade I-II and II-IV or Mallampati classification and number of ILMA insertion attempts or IDG. There was also no correlation between mouth opening, or thyromental distance and number of ILMA insertion attempts or IDG. It is concluded that easiness of ILMA use is irrelevant to mouth opening, thyromental distance, Mallampati classification or Cormack-Lehane Grade.

Ropivacaine spinal anesthesia is not antagonized by ondansetron pretreatment.

BACKGROUND: We investigated a possible effect of ondansetron on the duration of sensory and motor block produced by ropivacaine. METHODS: Fifty male patients undergoing transurethral surgery received either 8 mg oral ondansetron the evening before surgery plus IV 8 mg ondansetron 15 min before subarachnoid anesthesia or placebo. All patients received 2.2 mL of 0.75% plain ropivacaine intrathecally. Sensory and motor block were assessed 30 min after the intrathecal injection and every 30 min thereafter until recovery from the motor block. RESULTS: Thirty minutes after spinal injection of ropivacaine, we first measured, in both groups, the time to maximum block for both sensory and motor modalities. The maximum level of the sensory block, defined as decreased sensation, was T8 in the control and T6 in the ondansetron group, and absence of sensation was defined as T11 and T9 for the control and the ondansetron groups, respectively. Regarding block duration, 180 min after spinal injection, sensory block was detected in 11 of 22 and 16 of 24 patients and motor block in 1 of 22 and 0 of 24 in the control and ondansetron groups, respectively. Sensory and motor block did not differ between groups at any measured time point. CONCLUSIONS: Ondansetron had no effect on the subarachnoid sensory or motor block produced by ropivacaine.

Intravenous morphine and droperidol after caesarean delivery under subarachnoid anaesthesia has no effect on postoperative pain or analgesic requirements.

BACKGROUND AND OBJECTIVE: Opioids are routinely administered to obtain a better control of postoperative pain. The aim of the present study was to assess the intravenous morphine effect after caesarean delivery on the postoperative morphine requirements and pain. METHODS: Sixty-two parturients undergoing elective caesarean section under subarachnoid anaesthesia were randomly assigned in a double-blinded manner to the morphine or to the control group, to receive intraoperatively 0.15 mg kg morphine in 100 ml of isotonic saline or equal volume of normal saline. Postoperative analgesia was ensured with patient-controlled analgesia morphine. Postoperative pain at rest and after cough was assessed using the visual analogue scale (VAS) 2, 4, 8, and 24 h. Morphine consumption was recorded at the same time points. RESULTS: Cumulative morphine consumption 2, 4, 8, and 24 h postoperatively was 6 +/- 4.8, 14 +/- 6.6, 22 +/- 9.6, and 42 +/- 15.7 mg in the morphine and 8 +/- 5.1, 18 +/- 7.7, 28 +/- 9.4, and 43 +/- 17.4 mg in the control group (F = 2.70, DF = 1, and P = 0.105 for intergroup comparisons). The VAS scores at rest did not differ between the two groups, being 28 +/- 22.3, 40 +/- 21.4, 28 +/- 18.5, and 28 +/- 22.2 mm in the morphine group and 28 +/- 21.5, 43 +/- 23.5, 29 +/- 24.2, and 19 +/- 24.8 mm in the controls (F = 0.37, DF = 1, P = 0.848). Similar results apply to the VAS scores recorded after cough. VAS values were 35 +/- 20.6, 51 +/- 22.5, 42 +/- 18.2, and 46 +/- 23.6 mm in the morphine and 40 +/- 22.1, 54 +/- 28.9, 47 +/- 26.5, and 38 +/- 26.9 mm in the control group, respectively. CONCLUSION: Morphine given after caesarean delivery under subarachnoid anaesthesia has no effect on analgesic requirements or acute postoperative pain.

Pregnancy at term does not alter the responses to a mechanical and an electrical stimulus after skin EMLA application.

BACKGROUND: Pregnancy is associated with reduced local anesthetic requirements and increased pain thresholds, possibly due to hormonal changes and activation of endogenous opioids. METHODS: We compared the responses to a mechanical and an electrical stimulus in 30 pregnant women (pregnant group) scheduled for cesarean section and 30 healthy female volunteers (control group) matched for age. Pain was assessed by Visual Analogue Scale (VAS) on two different days after skin application of EMLA or placebo cream on the forearms. EMLA and placebo cream were randomly applied on the medial surface of both forearms for 30 min in a blind cross over manner and the subjects received a mechanical stimulus generated through a pressor palpator followed by an electrical stimulus generated through a nerve stimulator. RESULTS: Average VAS values from both trials did not differ between pregnant and control group exposed to the mechanical or electrical stimulus after EMLA application or after mechanical or electrical stimulus after placebo cream application.. CONCLUSIONS: Late pregnancy is not associated with increased sensitivity to local anesthetics (EMLA) applied to the skin, under our study conditions.