Techniques for identifying the epidural space: a survey of practice amongst anaesthetists in the UK.

A postal survey of all UK members of the Obstetric Anaesthetists' Association was carried out to ascertain their preferred method for identifying the epidural space in obstetric and non-obstetric patients. Over 1200 questionnaires were returned (79.3% response rate). In obstetric patients, the single most common technique (used by 58% of anaesthetists) was continuous advancement of the epidural needle and loss of resistance with saline, followed by intermittent needle advancement with air (21%). A minority of respondents used other variants, including intermittent advancement with saline (16%) and continuous advancement with air (4%). Consultant anaesthetists showed greater variety in techniques used than did trainees (p < 0.001). Less than 5% of respondents used a paramedian approach, and these were almost exclusively senior staff. Only 48% of anaesthetists said they would try an alternative if they experienced difficulty with their preferred technique. A similar pattern was seen for lumbar epidurals in non-obstetric surgical patients (89% used the same technique as in obstetrics), although for thoracic epidurals, 23% used a different technique to that which they would use for obstetrics, and the paramedian approach was more popular (21%). When inserting lumbar epidurals to supplement general anaesthesia in surgical patients, 18% of anaesthetists said they usually performed the block with the patient asleep, whereas for thoracic epidurals, this figure fell to 14%.

A comparison of epidural ropivacaine 0.75% and bupivacaine 0.5% with fentanyl for elective caesarean section.

BACKGROUND: Early studies suggested that ropivacaine had clinical advantages over bupivacaine with respect to cardiotoxicity and motor block, and that it was suitable for epidural caesarean section. This study was set up to compare epidural 0.75% ropivacaine with a popular bupivacaine/fentanyl mixture for elective caesarean section. METHODS: Eighty women having elective caesarean section under epidural anaesthesia were randomly allocated to receive 20 mL of either 0.75% ropivacaine or 0.5% bupivacaine plus fentanyl 100 microg. Supplementation with 2% plain lidocaine was used where necessary. Times were recorded for onset of sensory block, density and duration of motor block, and the need for supplementation. RESULTS: There was no difference between the groups in the time (mean [SD]) to achieve sensory blockade to cold to T4 (ropivacaine 15.8 [5.6] min, bupivacaine/fentanyl 18.7 [9.1] min, P=0.13) or to S1 (ropivacaine 18.3 [4.6] min, bupivacaine/fentanyl 17.4 [7.6] min, P=0.59), or in the need for supplementation. However, ropivacaine produced a motor block that was denser (median Bromage score ropivacaine 3, bupivacaine/fentanyl 1.5, P=0.0041), and of longer duration (ropivacaine 237 [84] min, bupivacaine/fentanyl 144 [76] min, P<0.0001). CONCLUSIONS: This study suggests that epidural 0.75% ropivacaine without opioid may be used as an alternative to bupivacaine 0.5% with fentanyl for elective caesarean section, but it does not induce anaesthesia any faster and may result in a denser, more prolonged, motor block.

Administration of drugs outside of Product Licence: awareness and current practice.

An interactive audience response system was used to collect information from members of the Obstetric Anaesthetists' Association at the 1997 Annual Meeting about the drug use that is unsupported by the Product Licence. The responses confirm that both licensed and unlicensed drugs are widely used in clinical practice outside the limitations imposed by Product Licence. The commonest types of unlicensed administration in obstetric anaesthetic practice are the use of mixtures and epidural or spinal administration of opioids. Despite widespread awareness of the subject, there appears to be considerable ignorance about the indications for which many commonly used drugs are licensed, even amongst a specialist audience. A majority of audience members expressed a view that the OAA should play a pro-active role, either by polling members about their current practice, or by issuing guidelines on reasonable drug practice in obstetric anaesthesia, or both. Potential implications of these are discussed.

Physostigmine: going ... going ... gone? Two cases of central anticholinergic syndrome following anaesthesia and its treatment with physostigmine.

Two patients presented with very different signs of central anticholinergic syndrome following general anaesthesia for which they had received premedication with hyoscine. Both responded dramatically to 1 mg of intravenous (i.v.) physostigmine, which produced a rapid return to a normal level of consciousness. The aetiology of central anticholinergic syndrome is multi-factorial, but the diagnosis should be considered in all patients who demonstrate abnormal post-anaesthetic awakening. It is recommended that 1 mg of intravenous physostigmine is a safe and effective treatment for central anticholinergic syndrome, and that a supply of this important drug must be kept readily available in the recovery area of the operating theatre department.

Patient-controlled analgesia following caesarean section under general anaesthesia: a comparison of fentanyl with morphine.

This prospective, randomised, double-blind study compared PCA fentanyl with PCA morphine for post-Caesarean section analgesia. Following a standardised general anaesthetic, 37 women were allocated to receive either fentanyl (n = 18) or morphine (n = 19). The PCA was commenced after the women had been made comfortable in the postanaesthetic recovery room with the appropriate opioid solution (mean dose required = fentanyl 375 micrograms or morphine 16 mg). Initial PCA settings were bolus 1 ml (fentanyl 25 micrograms or morphine 1 mg), lockout time ten minutes, and no background infusion. Both analgesic solutions provided effective analgesia for a mean of 37 hr with high levels of patient satisfaction, and there were no differences in VAS scores for pain and patient satisfaction, or for side effects (nausea, itch, and sleepiness) between fentanyl or morphine. However, more patients in the fentanyl group required supplementary boluses or alterations to the PCA settings (13/18 vs 4/19: P = 0.005), and one patient was removed from the study due to inadequate analgesia. We conclude that fentanyl is not recommended for routine PCA use following Caesarean section.

Anaesthesia for the parturient with cystic fibrosis.

Cystic fibrosis is an inherited disorder that primarily affects the exocrine glands of the gastrointestinal and respiratory systems. It is commonly diagnosed at birth or shortly thereafter, and until recently few of these patients lived to reproductive age. However, as a result of improved medical care, there are now an increasing number of pregnancies in women with cystic fibrosis. We present the histories of two parturients with cystic fibrosis and discuss the anaesthetic and perinatal implications of this complex disease to their management.

Lupus anticoagulant, paramyotonia congenita and pregnancy.

A case report is presented of the anaesthetic management of a parturient with paramyotonia congenita and lupus anticoagulant antibodies. She had been treated with prophylactic, subcutaneous heparin and aspirin throughout her pregnancy. Epidural analgesia was provided for labour and delivery.

An experience of war surgery and wounds presenting after 3 days on the border of Afghanistan.

The International Committee of the Red Cross (ICRC) has run hospitals for the wounded of the conflict in Afghanistan since 1981. For political and geographical reasons the hospitals are situated in Pakistan, some distance from the fighting, and so the wounded may take many days to arrive. This has enabled a surgical team provided by the British Red Cross Society to observe wounds of varying age and degrees of putrefaction or healing. Twenty-nine (29) patients with wounds of 3 or more days are detailed. The old wounds showed a tendency either to putrefaction or healing and the surgical management had to be revised accordingly. Wounds sutured in the field tended to putrefy. Among the various problems, the most taxing and difficult were the cultural and religious objections to amputation. The ICRC is committed to providing surgical hospitals for the Afghan war wounded for as long as the conflict lasts. It has adapted the local facilities and staff to the particular political, geographical and cultural situation.