Anesthesia for cesarean section in a patient with placenta previa and methylenetetrahydrofolate reductase deficiency.

We describe the anesthetic management of a patient with placenta previa presenting for a cesarean section, who had methylenetetrahydrofolate reductase (MTHFR) deficiency. Methylenetetrahydrofolate reductase deficiency increases homocysteine levels in the body and, therefore, predisposes to thrombosis. After a cerebrovascular accident at 8 weeks of gestational age, the patient received anticoagulants throughout the course of her pregnancy. Bleeding from the placenta previa occurred at 30 weeks of gestational age. Although general anesthesia was indicated for this patient because of her hemodynamic instability and an anticoagulated state, nitrous oxide is contraindicated in such patients. Thus, we chose a subarachnoid block because the patient remained hemodynamically stable, and anticoagulation had been stopped 8 hours before surgery. To our knowledge, there is no reported case of a parturient with MTHFR deficiency complicated with a cerebrovascular accident and associated with placenta previa presenting for a cesarean section. Anesthetic considerations are discussed in patients presenting with placenta previa associated with MTHFR deficiency.

Infiltration of liposome bupivacaine into the transversus abdominis plane for postsurgical analgesia in robotic laparoscopic prostatectomy: a pilot study.

BACKGROUND: Transversus abdominis plane (TAP) infiltration has been increasingly used for postsurgical analgesia in abdominal/pelvic procedures; however, duration/extent of analgesia with standard local anesthetics is limited. This pilot study assessed the preliminary efficacy and safety of two volumes of liposome bupivacaine administered via TAP infiltration in patients undergoing robotic laparoscopic prostatectomy. METHODS: In this single-center, open-label, prospective study, patients older than 18 years received TAP infiltration with liposome bupivacaine immediately after surgery. The first 12 patients received a total volume of 20 mL liposome bupivacaine (266 mg); the next 12 received 40 mL liposome bupivacaine (266 mg). The liposome bupivacaine was diluted with 0.9% normal saline. The primary efficacy measure was duration of analgesia, measured by time to first opioid administration. Secondary outcome measures included patient-assessed pain scores, opioid use, and opioid-related adverse events (AEs). RESULTS: Twenty-four patients received liposome bupivacaine (20 mL, n=12; 40 mL, n=12) and were included in the primary analysis. Three refused participation in a 10-day follow-up visit and did not complete the study. Median time to first opioid administration after surgery was 23 and 26 minutes for the 20 and 40 mL groups, respectively. Mean total amount of postsurgical opioids ranged from 25.4 to 27.3 mg; after hospital discharge to day 10, both groups required a mean of 0.7 oxycodone/acetaminophen tablets/day. Mean pain scores of 4.4 and 5.3 were reported at 1 hour and 3.1 and 3.9 at 2 hours postsurgery, with 20 and 40 mL doses, respectively. Neither group had mean scores higher than 3.0 at any further assessments. No opioid-related or treatment-related serious AEs were reported. CONCLUSION: Median time to first opioid administration did not differ between the two groups. No differences in secondary outcomes were observed on the basis of volume administered. These initial findings suggest further study of liposome bupivacaine administered via TAP infiltration as part of a multimodal analgesic regimen in laparoscopic robotic prostatectomy may be warranted.

Preoperative interscalene block for elective shoulder surgery: loss of benefit over early postoperative block after patient discharge to home.

UNLABELLED: We performed a randomized, prospective, parallel-group, open-label, multicenter trial to compare the effects of pre- versus postoperative interscalene block using levobupivacaine on postoperative pain and analgesic requirements. One-hundred-two outpatients scheduled for elective shoulder surgery were randomized to receive 30 mL of 0.5% levobupivacaine either preoperatively (PRE group) or postoperatively (POST group). Analgesic outcome measures during the postoperative period were: (a). time to first request for analgesic medication after surgery, (b). pain intensity using the visual analog scale at rest and during arm movement, and (c). total analgesic consumption of nonsteroidal antiinflammatory drugs and opioids. The time to first analgesic request did not differ between treatment groups. However, mean maximum pain intensity scores during the day of surgery were significantly less for the PRE group than the POST group, both at rest (P = 0.001) and after movement (P = 0.004). The mean opioid administered during surgery was lower in the PRE than the POST group (P < 0.001). Levobupivacaine was well tolerated in both treatment groups, and no adverse reactions were related to this local anesthetic. In conclusion, preoperative interscalene block with levobupivacaine provided superior pain control for the first 12 h after surgery, but this benefit was not maintained during the week after discharge because the subjects assumed control of their own pain relief as outpatients. IMPLICATIONS: Preoperative interscalene block with levobupivacaine provides safe and effective analgesia for same-day elective shoulder surgery, but the benefit of this one-time intervention does not persist.