[Anesthesia for cesarean section in patients with preexisting neurologic diseases--10 years of practice]. / Znieczulenie do ciecia cesarskiego u pacjentek z choroba neurologiczna--10 lat doswiadczen.

OBJECTIVES: Regional anesthesia is considered a 'gold standard' for cesarean sections. However, it is very often contraindicated in patients with coexistent neurological diseases. This article attempts to review the specific concerns for administration of anesthesia for cesarean section posed by spinal diseases, epilepsy sclerosis multiplex and others. MATERIALS AND METHODS: We present 85 cases of parturients with pre-existing neurological diseases, who received anesthesia for caesarean section at the First Clinic of Anesthesia and Intensive Care in the last 10 years. We compared those cases with the medical literature. RESULTS: We successfully used general as well as regional anesthesia. The decision about the anesthetic technique was based on the neurological state of each patient. CONCLUSION: No guidelines for anesthesiologist concerning the best anesthetic technique for patients with neurological diseases have been designed so far. The choice of the safest method is made individually and depends on a variety of factors.

[Comparative study of postoperative analgesia after intrathecal administration of bupivacaine with fentanyl or morphine for elective Caesarean section]. / Analiza porównawcza podpajeczynówkowego zastosowania fentanylu lub morfiny w terapii bólu po operacji ciecia cesarskiego.

BACKGROUND: Various opioids have been recommended for spinal anaesthesia during Caesarean section. The aim of this prospective randomized, double-blind study was to compare the quality of postoperative analgesia and adverse effects after intrathecal administration of 0.5% hyperbaric bupivacaine (HB) combined with either morphine or fentanyl. METHODS: Sixty parturients were randomly allocated to receive intrathecally, 7.5-15 mg of HB with either 25 microg fentanyl (group F), or 100 microg morphine (group M). All women received 100 mg ketoprofen at 2 and 14 h after surgery, and 1.0 g paracetamol at 2, 8, 14 and 20 h after surgery. Additionally, meperidine was offered as a rescue analgesic via patient-controlled analgesia (PCA). During the first 24 h after surgery, pain intensity was evaluated using a VAS score, meperidine consumption was noted, and possible side effects were assessed. RESULTS: Mean PCA meperidine consumption was 47 mg and 130 mg, for groups M and F, respectively. Intrathecal morphine significantly prolonged the time to first PCA use, when compared to fentanyl. The mean VAS score was lower in group M. Pruritus was more frequently observed in group M. There was no significant difference in the incidence of postoperative nausea and vomiting between both groups. CONCLUSIONS: Both intrathecal morphine and fentanyl significantly reduced the intensity of postoperative pain. Morphine increased the duration of postoperative analgesia and reduced the demand for rescue meperidine.

Perioperative analgesia after intrathecal fentanyl and morphine or morphine alone for cesarean section: A randomized controlled study.

OBJECTIVES: Intrathecal morphine is used in the postoperative management of pain after caesarean section (CS), but might not be optimal for intraoperative analgesia. We hypothesized that intrathecal fentanyl could supplement intraoperative analgesia when added to a local anesthetic and morphine without affecting management of postoperative pain. METHODS: This prospective, randomized, double-blind, parallel-group study included 60 parturients scheduled for elective CS. Spinal anesthesia consisted of bupivacaine with either morphine 100 µg (M group), or fentanyl 25 µg and morphine 100 µg (FM group). The frequency of intraoperative pain and pethidine consumption in the 24 hours postoperatively was recorded. RESULTS: Fewer patients in the FM group required additional intraoperative analgesia (P < .01, relative risk 0.06, 95% confidence interval [CI] 0.004-1.04). The FM group was noninferior to the M group for 24-hour opioid consumption (95% CI -10.0 mg to 45.7 mg, which was below the prespecified boundary of 50 mg). Pethidine consumption in postoperative hours 1 to 12 was significantly higher in the FM group (P = .02). Postoperative nausea and vomiting (PONV) were more common in the FM group (P = .01). Visual analog scale scores, effective analgesia, Apgar scores, and rates of pruritus and respiratory depression were similar between the groups. CONCLUSIONS: Intrathecal combination of fentanyl and morphine may provide better perioperative analgesia than morphine alone in CS and could be useful when the time from anesthesia to skin incision is short. However, an increase in PONV and possible acute spinal opioid tolerance after addition of intrathecal fentanyl warrants further investigation using lower doses of fentanyl.

Analgesic efficacy of intrathecal fentanyl during the period of highest analgesic demand after cesarean section: A randomized controlled study.

Cesarean section (CS) is one of the most common surgical procedures in female patients. We aimed to evaluate the postoperative analgesic efficacy of intrathecal fentanyl during the period of greatest postoperative analgesic demand after CS. This period was defined by detailed analysis of patient-controlled analgesia (PCA) usage.This double-blind, placebo-controlled, parallel-group randomized trial included 60 parturients who were scheduled for elective CS. Participants received spinal anesthesia with bupivacaine supplemented with normal saline (control group) or with fentanyl 25 µg (fentanyl group). To evaluate primary endpoints, we measured total pethidine consumption over the period of greatest PCA pethidine requirement. For verification of secondary endpoints, we recorded intravenous PCA requirement in other time windows, duration of effective analgesia, pain scores assessed by visual analog scale, opioid side effects, hemodynamic changes, neonatal Apgar scores, and intraoperative pain.Detailed analysis of hour-by-hour PCA opioid requirements showed that the greatest demand for analgesics among patients in the control group occurred during the first 12 hours after surgery. Patients in the fentanyl group had significantly reduced opioid consumption compared with the controls during this period and had a prolonged duration of effective analgesia. The groups were similar in visual analog scale, incidence of analgesia-related side effects (nausea/vomiting, pruritus, oversedation, and respiratory depression), and neonatal Apgar scores. Mild respiratory depression occurred in 1 patient in each group. Fewer patients experienced intraoperative pain in the fentanyl group (3% vs 23%; relative risk 6.8, 95% confidence interval 0.9-51.6).The requirement for postoperative analgesics is greatest during the first 12 hours after induction of anesthesia in patients undergoing CS. The addition of intrathecal fentanyl to spinal anesthesia is effective for intraoperative analgesia and decreases opioid consumption during the period of the highest analgesic demand after CS, without an increase in maternal or neonatal side effects. We recommend using intrathecal fentanyl for CS in medical centers not using morphine or other opioids intrathecally at present.

[HELLP syndrome in the postpartum period]. / Zespól HELLP w pologu.

The HELLP syndrome was described by Weinstein as a complication of pregnancy induced hypertension (PIH). There are few clinical reports about HELLP during postpartum period. We present the history of 31 years old pregnant patient, who developed in 36 week of her first pregnancy PIH, pregnancy was terminated in 39 week by cesarean section and postpartum period was complicated with HELLP syndrome (class I). The patient was treated surgically (hysterectomy), than continue at ICU. The treatment was successful without any late organ complications.

[Retrospective assessment of epidural analgesia during labor according to parturients]. / Retrospektywna ocena znieczulenia zewnatrzoponowego porodu przez rodzace.

AIM: The aim of the study was to find out parturients' evaluation of epidural analgesia (EA) during labor and factors influencing their opinion. MATERIALS AND METHODS: 100 women, aged 26-42, who gave birth at I Department of Obstetrics and Gynaecology in Warsaw, filled in a specially prepared inquiry. Primiparas contributed to 87% of the study group. The results were analyzed according to analgesia evaluation as: very good (group A-64%), good (group B-30%) and insufficient (group C-6%). RESULTS: Patients evaluated their pain according to Visual Analog Scale before and after EA was applied in the I and II stage of labor, respectively. Significant differences regarding the pain level in the II stage were observed--among patients from group C it was even higher than before EA was applied. That group more often notified perineum pain during the II stage of labor. Feeling uterine contractions, tenesmus and drugs' side effects had no influence on women's opinion. The way of grading EA depended on parity and education--patients from group C were all well-educated primiparas. The time of making a decision about willing to give birth with EA also depended on parity--multiparas decided earlier than primiparas. Women's main source of information about labor EA were press and books (56%), than labor school (26%), other women (24%) and only for 20% their gynaecologist. In spite of the differences in their answers, the majority of women would decide on labor EA again (95%) and recommend it to others (98%). CONCLUSIONS: The majority of patients gives labor EA very positive opinion. Insufficient pain control in the II stage of labor and perineum pain are the main factors lowering EA evaluation--it seems important to pay more attention to that fact in the future. Time of making a decision about EA and women's opinion depend on parity. As press is the main source of information for patients, the wider promotion of EA by medical staff seems necessary.

The course of pregnancy and delivery in a patient after a double-outlet right ventricle Fontan repair and the influence of this procedure on her general condition: report of a case.

The course of pregnancy and delivery in a patient after Fontan repair of double-outlet right ventricle is herein presented. She uneventfully delivered a healthy infant in good general condition at 38 weeks of gestation through a caesarean section, at 24 years after cardiosurgery. Although the patient demonstrated a good hemodynamic state after the operation and conceived while being clinically stable, a worsening of her general condition was observed. After a 4-year follow-up it was clear that pregnancy and delivery had a harmful effect on her cardiovascular function.