The effects of fentanyl, oxycodone, and butorphanol on gastrointestinal function in patients undergoing laparoscopic hysterectomy: a prospective, double-blind, randomized controlled trial.

BACKGROUND: Perioperative opioid use is associated with postoperative bowel dysfunction, which causes longer hospital stay and higher healthcare costs. This study aimed to investigate the effect of the equivalent doses of fentanyl, oxycodone, and butorphanol on bowel function in patients undergoing laparoscopic hysterectomy. METHODS: In this randomized controlled trial, 135 patients undergoing laparoscopic hysterectomy received postoperative intravenous patient-controlled analgesia (IV-PCA) with fentanyl 8.3 µg/kg, butorphanol 0.16 mg/kg, and oxycodone 0.5 mg/kg (1: 20: 60), respectively. The primary outcome measure was the recovery of bowel function. We also evaluated and recorded the following nine indicators: pain score, sedation level, leukocyte count, percentage of neutrophils, plasma potassium levels, time to first ambulation, postoperative side effects, patients' satisfaction, and postoperative hospital length of stay. RESULTS: The mean time to flatus was significantly prolonged in Group B (45.2 ± 11.6 h) compared with Group F (33.1 ± 11.2 h, P < 0.001) and Group O (36.2 ± 10.9 h, P = 0.001). The incidence of somnolence and dizziness prove higher in Group B (P < 0.001). No statistical difference was observed in the mean time to tolerate oral diet, time to defecation, analgesic outcome, satisfaction score, time to first ambulation, and postoperative hospital length of stay. CONCLUSIONS: Compared with fentanyl and oxycodone, butorphanol prolonged the recovery of bowel function with more severe somnolence and dizziness, suggesting that butorphanol is not well suitable for IV-PCA in patients undergoing laparoscopic hysterectomy. TRIAL REGISTRATION: ClinicalTrials.gov- NCT04295109 . Date of registration: March, 2020.

Effect and placental transfer of dexmedetomidine during caesarean section under epidural anaesthesia.

Objective To investigate the neonatal effect and placental transfer of dexmedetomidine during caesarean section under epidural anaesthesia. Methods Forty parturients with a single newborn who were scheduled for caesarean section were enrolled. Patients received 0.5 µg/kg dexmedetomidine 10 min after epidural anaesthesia, followed by 0.5 µg/kg/h until abdominal closure (Dex group) or infusion of normal saline (NS group). Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were monitored before infusion (T0), 10 min after infusion (T1), at delivery (T2), and at the end of the operation (T3). Umbilical vein and artery blood was collected. Apgar scores were evaluated at 1 and 5 min after delivery. Results SBP, DBP, and HR in the Dex group were decreased at T3 compared with T0 (116 ± 10.4 vs 111 ± 9.2 mmHg, 74 ± 6.7 vs 66 ± 7.9 mmHg, 91 ± 12.1 vs 71 ± 8.4 beats/min, respectively, P < 0.05). HR was lower at T1, T2, and T3 in the Dex group compared with the NS group ( P < 0.05). There were no significant differences in blood gases and Apgar scores between the groups ( P > 0.05). Conclusion Dexmedetomidine during caesarean section under epidural anaesthesia is beneficial to parturients. The placental transfer rate is 0.68.

Clinical effects of sevoflurane anesthesia induction with a portable inhalational anesthetic circuit in pediatric patients.

INTRODUCTION: Pediatric anesthesia induction with sevoflurane usually needs a special vaporizer and gas source, which limits its use to the operating room (OR). Many children feel anxious and cry when entering the OR because of being separated from their parents, which impairs anesthesia safety and their physical and mental health. In this study, we used a portable circuit to perform sevoflurane anesthesia induction outside the OR, assessed its effects and compared them with those of ketamine anesthesia in pediatric patients. MATERIAL AND METHODS: One hundred children had anesthesia induced with either sevoflurane (sevoflurane group) through the portable inhalational anesthetic circuit, or ketamine by intramuscular injection (ketamine group), then were transferred to the OR. Peak inspired concentration (Cp) and steady state concentration (Cs) of sevoflurane were measured. Heart rate (HR) and saturation of peripheral oxygen (SpO2) were monitored. Time for anesthesia induction, awakening, leaving the OR and duration of the operation were recorded. The patients' reaction during anesthesia was also analyzed. RESULTS: The Cp and Cs of sevoflurane were correlated with bodyweight. Compared with the ketamine group, the sevoflurane group showed shorter time for anesthesia induction (28 ±7 s vs. 195 ±34 s, p < 0.0001), awakening (11.2 ±3.6 s vs. 63.5 ±6.7 s, p < 0.0001) and leaving the OR (20.5 ±5.6 s vs. 43.4 ±10.6, p < 0.0001), less noncooperation during anesthesia induction (10% vs. 80%, p < 0.0001), lower HR (130 ±16 beats/min vs. 143 ±19 beats/min, p = 0.0004) and higher SpO2 (98.9 ±0.9% vs. 96.1 ±2.5%, p < 0.0001) on arrival at the OR. CONCLUSIONS: Pediatric anesthesia induction by sevoflurane with the portable inhalational anesthetic circuit is convenient, safe and effective outside the OR.

Effect and Placental Transfer of Dexmedetomidine During Caesarean Section Under General Anaesthesia.

Many drugs can pass through the placenta and cause adverse effects on the foetus. Thus, during Caesarean section for puerperas who have contraindications for intravertebral anaesthesia, the use of proper drugs that have sedative, analgesic effects on the puerperas without adverse effects on the foetus is important. In this study, we investigated the effect and placental transfer of dexmedetomidine during Caesarean section under general anaesthesia. Thirty-eight puerperas were randomly divided to receive dexmedetomidine or saline before anaesthesia induction and during the operation. The dexmedetomidine-treated parturients had lower mean arterial pressure and heart rate at the delivery and at the end of the operation. The dexmedetomidine-treated parturients also needed 5.5% less propofol and 8.4% less fentanyl than the saline-treated ones. Between the dexmedetomidine-treated and saline-treated parturients, there was no difference in the maternal artery, umbilical vein, umbilical artery blood gas analysis results and the Apgar scores at 1 and 5 min. after delivery. The placental transfer rate of dexmedetomidine was 0.76. We concluded that dexmedetomidine was effective in maintaining the haemodynamic stability in the parturients during Caesarean section under general anaesthesia without adverse neonatal effects. Dexmedetomidine can pass through the placenta with a placental transfer rate of 0.76.

Effects of epinephrine in the epidural space on the incidence of blood vessel injury by epidural catheter insertion for cesarean section: a prospective, randomized, double-blind study.

STUDY OBJECTIVE: To evaluate the effects of epinephrine (1:200,000) in the epidural space on the incidence of blood vessel injury by epidural catheter insertion for cesarean section. DESIGN: Prospective observational study. SETTING: University-affiliated teaching hospital. PATIENTS: Four hundred laboring women with singleton cephalic presentations at term who underwent cesarean section and requested continuous epidural analgesia. INTERVENTIONS: Predistension of 5 mL of isotonic sodium chloride solution containing epinephrine (1:200,000) or 5 mL of isotonic sodium chloride solution through an epidural needle before catheter insertion. MEASUREMENTS: Cases with bloody fluid in the epidural needle or catheter during catheter insertion, aspiration of frank blood from the epidural catheter, and blood noted in the caudal end of the epidural catheter upon removal were recorded. MAIN RESULTS: Eight parturients were excluded from the analysis for technical reasons. There were no significant differences between patients in the 2 groups with respect to cases with bloody fluid in the epidural needle during catheter insertion (7.6% vs 9.8%, P = .44), the epidural catheter during catheter placement (6.0% vs 6.7%, P = .80), aspiration of frank blood in the epidural catheter (1.0% vs 1.0 %, P = .98), and blood noted in the caudal end of the epidural catheter upon removal (27.3% vs 30.4 %; P > .49). CONCLUSION: Twenty-five micrograms of epinephrine (1:200,000) in the epidural space does not reduce the incidence of blood vessel injury induced by insertion of an epidural catheter.

[Application of dexmedetomidine combined with ropivacaine in the cesarean section under epidural anesthesia].

OBJECTIVE: To explore the anesthetic effect and neonatal effects of dexmedetomidine combined with ropivacaine in the cesarean section under epidural anesthesia. METHODS: Between January 2012 and March 2013 at the First Affiliated Hospital with Nanjing Medical University, sixty parturients with a single baby at full term in vertex presentation scheduled for caesarean section under epidural anesthesia, were randomly divided into 3 groups (n = 20 each) according to the random digits table: dexmedetomidine + ropivacaine (RD), fentanyl + ropivacaine (RF) and normal saline + ropivacaine (RN). After identification of the epidural space and a negative aspiration test for blood or cerebrospinal fluid, 15 ml of 0.75% ropivacaine, was administered epidurally in three the groups with addition of 1 µg/kg of dexmedetomidine in RD group, 1 µg/kg of fentanyl in RF group and 2 ml of normal saline in RN group. Recording the mean arterial pressure (MAP) and heat rate (HR) before anesthesia (T(0)), at 10 min (T(1)) and 30 min (T(2)) after the end of epidural administration, and at end of operation (T(3)). Recording the onset time, maximum sensory analgesic level, time to maximum sensory analgesic level, time to two segmental dermatomal regressions, and time to chief complaint of postoperative pain. The modified bromage degrees, sedation scores and traction reaction were also assessed. The Apgar scores at 1 and 5 min were also recorded after delivery, and the blood samples were drawn from umbilical vein for gas analysis. RESULTS: MAP, HR and the motor block (Bromage scale) were no statistics differences among the three groups (P > 0.05) . Compared with RN group, the onset time and the time to maximum sensory analgesic level were significantly earlier [(6.3 ± 2.4), (8.7 ± 2.3) min vs (10.9 ± 2.7) min; (11.5 ± 3.9), (16.2 ± 4.6) min vs(19.8 ± 5.2) min, P < 0.05], the time to two segmental dermatomal regressions and the time to chief complaint of postoperative pain were prolonged significantly[(22.5 ± 4.6), (18.5 ± 3.9) min vs (13.5 ± 3.8) min; (415 ± 92), (355 ± 86) min vs( 273 ± 68) min, P < 0.05], level of sedation and degree of traction reaction were better in RD group and in RF group, and the incidence of shivering was lower in RD group (5% vs 40%, P < 0.05), the incidence of dizziness was higher in RF group (20% vs 0, P < 0.05). Compared with RF group, the same results were also seen about the onset time, the time to maximum sensory analgesic level, the time to two segmental dermatomal regressions and the time to chief complaint of postoperative pain, and the level of sedation was better, the incidence of drowsiness was lower in RD group. There were no statistics differences about both the blood gas analysis of umbilical vein and the Apgar scores at 1 and 5 min after delivery. CONCLUSION: Administration of dexmedetomidine combined with ropivacaine can provide early onset, establishment of sensory anesthesia, much better sedation levels, decrease the degree of traction reaction and the incidence of shivering, and without adverse neonatal effects.

[Effects of preloading epidural space with epinephrine (1:200 000) on the incidence of vascular injuries through the insertion of an epidural catheter during cesarean section].

OBJECTIVE: To evaluate the effects of preloading epidural space with epinephrine (1:200 000) on the incidence of vascular injuries through the insertion of an epidural catheter during cesarean section. METHODS: Between May 2011 and December 2011, upon obtaining institutional ethics approval and informed consent from the Human Ethics Committee of Nanjing Medical University, 100 laboring women with singleton cephalic presentation at term, ASA (American Society of Anesthesiologists) class I-II, undergoing caesarean section under continuous epidural analgesia were randomly divided into E and N groups according to a random digit table (n = 50 each). After an identification of epidural space, 5 ml of normal saline with epinephrine (1:200 000) was injected into epidural space in group E and 5 ml of normal saline in group N through an epidural needle. The syringe plunger was pressed firmly for 20 seconds to ensure a sufficient diffusion. For both groups, the levels of mean arterial pressure and heart rates were recorded prior to anesthesia (T1), 2 min after switching into a supine horizontal position after successful puncture (T2), the time of fetal delivery (T3) and when surgery was over (T4). The cases with bloody fluid in epidural puncture needle during puncture or epidural catheter during catheter placement, fresh blood in epidural catheter and bloody fluid in caudal end of epidural catheter during extubation were recorded. RESULTS: All hemodynamic changes were within the normal ranges. There were no obvious inter-group differences (P > 0.05). No significant difference existed in the cases with bloody fluid in epidural needle during catheter insertion (10% vs 12%) or epidural catheter during catheter placement (4% vs 6%), fresh blood in epidural catheter (0% vs 0%) or bloody fluid in caudal end of epidural catheter during extubation (26% vs 30%) between the groups (P > 0.05). CONCLUSION: Preloading epidural space with epinephrine (1:200 000) may not lower the incidence of vascular injuries through the insertion of an epidural catheter during cesarean section.

Comparison of the stress response in patients undergoing gynecological laparoscopic surgery using carbon dioxide pneumoperitoneum or abdominal wall-lifting methods.

BACKGROUND: Conventional laparoscopy is aided by CO(2) insufflation, but this may impair cardiorespiratory function, induce stress responses, and result in life-threatening complications. CO(2) insufflation is usually conducted under general anesthesia, whereas gasless laparoscopy supposedly eliminates most of these disadvantages. In this study, we compared the changes of concentration of serum cortisol, tumor necrosis factor alpha (TNF-alpha), interleukin (IL)-6, IL-10, and heat shock protein 70 (Hsp70) in patients undergoing gynecological laparoscopic surgery in order to explore the severity of the stress response following CO(2) pneumoperitoneum or abdominal wall-lifting methods combined with the different anesthetic techniques performed. SUBJECTS AND METHODS: Fifty-seven patients scheduled for gynecological laparoscopy from July 2009 to February 2010 with American Society of Anesthesiologists I-II evaluation and scheduled operation times of less than 100 minutes were randomly divided into three groups (GC, GG, or EG) with 20 patients in each group. Group GC patients were operated on with the aid of CO(2) insufflation under general anesthesia. Group GG patients were operated on under general anesthesia using the gasless technique. Group EG patients underwent the same operative procedures under epidural anesthesia using the gasless technique. Serum cortisol, TNF-alpha, IL-6, IL-10, and Hsp70 were detected and analyzed at four time points: Before anesthesia (T(1)), 30 minutes after the beginning of the operation (T(2)), 10 minutes after the end of surgery (T(3)), and at 8:00 a.m. the following day (T(4)). RESULTS: There were no obvious differences in the levels of serum cortisol, TNF-alpha, IL-6, IL-10, or Hsp70 among the groups at T(1) (P>.05), but these values increased after the beginning of the operation and peaked in Group GC at T(3) and in Group GG and Group EG at T(4). The levels of serum cortisol and TNF-alpha were higher in Group GC than in Group GG at T(2) (P<.05). At T(3), levels of serum cortisol, TNF-alpha, IL-6, and Hsp70 were significantly higher in Group GC than in Group GG (P<.01) and were the same as the changes of IL-6 to IL-10 ratio (P<.05), while serum concentrations of cortisol, TNF-alpha, and IL-6 were also significantly higher in Group GG than in Group EG (P<.05). CONCLUSIONS: Gynecological laparoscopic surgery using abdominal wall-lifting methods could avoid the deleterious effects of CO(2) pneumoperitoneum, and reduce the stress response. The lowest stress response was found when abdominal wall-lifting methods were used with the patient under epidural anesthesia.

[Comparison of effects in puerpera and fetus with ephedrine and phenylephrine during a cesarean delivery].

OBJECTIVE: To compare the different effects in fetus and puerpera with an equivalent dose of ephedrine (E) and phenylephrine (Ph) for maintaining maternal blood pressure near baseline during spinal anesthesia for a cesarean delivery. METHODS: Ninety mature parturient women with single-embryo scheduled for an elective cesarean delivery under spinal anesthesia at our hospital during January-June 2010 were randomly divided into 3 groups (E, E + Ph and Ph, n = 30 each). Group E received an infusion of ephedrine (ephedrine 4 g/L), Group E + Ph ephedrine plus phenylephrine (ephedrine 2 g/L + phenylephrine 25 mg/L) and Group Ph phenylephrine (phenylephrine 50 mg/L). The blood pressure was maintained near baseline by adjusting the infusion rate during anesthesia. The maternal blood pressure, heart rate and fetal heart rate were measured at the time points of 1, 3, 5 and 10 min, skin incision and uterine incision after injecting anesthetic into subarachnoid space. Immediately after delivery, maternal arterial, umbilical arterial and umbilical venous blood samples were withdrawn for the measurements of blood gases and plasma concentrations of lactate and glucose. RESULTS: The fetal heart rate of groups E and E + Ph significantly increased after infusion [5 min: (150 ± 10) times/min vs (142 ± 13) times/min, (146 ± 10) times/min vs (142 ± 9) times/min, both P < 0.05] while those of group Ph had no significant changes [5 min: (143 ± 9) times/min vs(143 ± 6) times/min, P > 0.05]. The incidence of fetal tachycardia in groups E and E + Ph was greater than that in group Ph. In group E, umbilical arterial and umbilical venous pH and base excess were lower than those in groups E + Ph and Ph [umbilical arterial: 7.20 ± 0.10 vs 7.27 ± 0.05, 7.28 ± 0.03, (-3.1 ± 3.1) mmol/L vs (-0.9 ± 1.7) mmol/L, (-0.3 ± 1.7) mmol/L, umbilical venous:7.29 ± 0.09 vs 7.34 ± 0.03, 7.34 ± 0.03, (-3.3 ± 2.9) mmol/L vs (-2.0 ± 1.7) mmol/L, (-0.9 ± 1.5) mmol/L, all P < 0.05]. Umbilical arterial PCO2 and plasma concentrations of lactate and glucose in group E were greater than those in group Ph (all P < 0.05). Umbilical arterial and umbilical venous plasma concentrations of lactate and glucose were greater in group E + Ph than those in group Ph (all P < 0.05). But base excess was lower (P < 0.05). CONCLUSION: Phenylephrine may be more ideal for treating the hypotension of spinal anesthesia for a cesarean delivery. It corrects hypotension following spinal anesthesia, improves fetal oxygen supply and demand balance but induces no metabolic excitation in fetus as compared with ephedrine.