Lidocaine-prilocaine (EMLA) cream as analgesia for hysterosalpingography: a prospective, randomized, controlled, double blinded study.

BACKGROUND: The aim of our study is to evaluate the efficacy of applying lidocaine 25 mg-prilocaine-25 mg/G cream (EMLA 5%) on the uterine cervix for pain relief when performing hysterosalpingography (HSG). METHODS: Eighty-two patients undergoing HSG as part of infertility evaluation were randomized into groups receiving EMLA (42) or placebo cream (40) in a double-blinded prospective study from which four women were later excluded. The cream was applied to the uterine cervix by means of a cervical cup 30 min before the HSG. Pain perception related to the HSG procedure was scored by visual analogue scale (VAS) at five predefined steps: after speculum application, after cervical instrumentation of the tenaculum and cannula, at the end of uterine filling, at completion of tubal spillage, and immediately following instrument removal. In addition, the patients were asked to retrospectively rate the pain during the entire procedure in a telephone interview the following day. RESULTS: Cervical instrumentation was found to be the most painful step of HSG (P < 0.001). When comparing the VAS pain scores, cervical instrumentation in the EMLA-treated patients was associated with significantly less pain than the control group: 3.3 +/- 2.9 versus 4.9 +/- 2.7, respectively (P = 0.02). CONCLUSIONS: Topical application of EMLA 5% cream on the uterine cervix before performing HSG significantly reduced the pain during this procedure.

Anesthesia for obstetric patients with Gaucher disease: survey and review.

Pregnancy and delivery in patients with non-neuronopathic Gaucher disease, whether treated with enzyme replacement or untreated, are usually uncomplicated. Various factors may influence mode of delivery, vaginal or cesarean section, as well as type of anesthesia, general or regional, used during delivery. This retrospective review was intended to highlight some of the practical issues relating to obstetric anesthetic management, based on a review of the literature and experiences from a large referral clinic for Gaucher disease. In the past decade, there were 16 deliveries in 11 women in our institution. There were five normal vaginal deliveries, two vacuum extractions, one placental extraction, and eight cesarean sections. Platelet counts were 27-215 x 10(9)/L. Two spontaneous deliveries and one vacuum extraction were performed under epidural anesthesia; two other women having vaginal deliveries and one vacuum extraction were given i.v. analgesia; the fifth was given i.v. patient-controlled analgesia. The placental extraction was performed under general anesthesia. Seven of the women having cesarean deliveries received spinal anesthesia; the breech presentation required general anesthesia. There were no anesthesia-related side effects or complications, although there were some instances of post-partum bleeding irrespective of enzyme therapy. Gaucher disease affects multiple organs and can be a challenge to the anesthesiologist. Based on this survey we suggest that anesthetic management requires particular attention to hematological parameters before delivery. A multidisciplinary approach and extensive communication among obstetrician, hematologist and anesthesiologist is required to anticipate the possibility of post-partum hemorrhage, and preclude skeletal damage.

The effect of meperidine on the guinea pig extrahepatic biliary tract.

The effect of meperidine on the mechanical activity of isolated guinea pig common bile duct (CBD) and gallbladder was studied in vitro. The effect was found to consist of inhibitory and excitatory phases. The inhibitory phase, characterized by a decrease in the response of the CBD and gallbladder to carbachol and electrical stimulation, was seen with concentrations of 10(-6) M or higher. The excitatory phase, seen at high concentrations of meperidine (5 X 10(-5)-10(-4) M), involved an increase in spontaneous contractions of CBD and in the tone of the gallbladder. Neither effect of meperidine was affected by 0.5 X 10(-5) M naloxone. These data indicate that meperidine acts on the biliary tract by a mechanism different from that associated with the effect of morphine.

Effect of morphine on the mechanical activity of common bile duct isolated from the guinea pig.

The contractile response of isolated guinea pigs common bile ducts (CBD) to transmural electrical stimulation and the effects of morphine and naloxone was studied. Contractile responses increased as a function of stimulus frequency. In the absence of naloxone morphine inhibited the contractile response to electrical stimulation in a dose-dependent manner. Naloxone prevented the inhibitory effect of morphine on the contractile response to electrical stimulation. We conclude that smooth muscle of the CBD in guinea pig is functional and can contribute to biliary motility, and that opiate receptors exist in nerve elements in the CBD.

Effect of nalbuphine on intrabiliary pressure in the early postoperative period.

The effect of nalbuphine on common bile duct (CBD) pressure was studied by measurements through T-tubes on the first and second postoperative days after cholecystectomy and choledochotomy. Nalbuphine in a dose of 0.25 mg X kg-1 was injected intramuscularly in 11 patients, and changes in biliary pressure, heart and respiratory rate, blood pressure, and arterial blood gases were recorded during the subsequent four hours. The patients were free of pain, had stable common bile duct pressures and did not have any statistically significant changes in their vital signs. These results are similar to our previous observations during perioperative intravenous injection of nalbuphine. It is suggested that nalbuphine does not significantly change, or even may relax, the sphincter of Oddi, and can therefore be recommended as a safe analgesic in the postoperative period after extrahepatic biliary surgery.

"Conscious sedation" for laparoscopy.

End-tidal pCO2, mean arterial blood pressure, heart rate and respiratory rate changes during diagnostic gynecological laparoscopy were studied in 30 healthy women by the technique of "conscious sedation" combined with local anesthesia of the skin and peritoneum. No significant hypercarbia or hypoxia was noted. Patients were discharged from hospital within 6 to 8 h of the laparoscopy; all noted their full satisfaction with this method of anesthesia. "Conscious sedation" appears to be a safe and efficient method for short diagnosis laparoscopies in young, nonobese, otherwise healthy patients in whom full general anesthesia is refused or considered inadvisable.

Mechanism of antagonism by physostigmine of acute flunitrazepam intoxication.

The effect of physostigmine on the loss of consciousness and respiratory depression induced in rabbits by flunitrazepam, 1 mg/kg, was studied to demonstrate whether the restoration of consciousness and respiration rate results from an increase in central cholinergic activity or from an interference by physostigmine with specific binding of flunitrazepam to its receptors. Physostigmine, 0.1-0.4 mg/kg iv, caused a dose-related reversal of consciousness and respiration rate within 15 min of its injection, which lasted 15-30 min depending on the dose. This was associated with peak inhibition of acetylcholinesterase (AChE) in the frontal cortex and medulla, at 15 min, ranging from 35-51%. The analeptic effect of physostigmine in flunitrazepam-treated rabbits was prevented by pretreatment with scopolamine, 1 mg/kg. The effective dose range for physostigmine, 3-12 mumol/kg, is close to concentrations of this agent that inhibit activity in solubilized preparations of AChE from rabbit cortex, 1-3 X 10(-8) M. However, physostigmine, 10(-9) -10(-4) M, failed to displace 3H flunitrazepam from specific binding sites on membranes prepared from rabbit cerebral cortex. It is concluded that physostigmine antagonizes the somnolence and respiratory depression induced by benzodiazepines by restoring cholinergic transmission to normal levels. The effective dose range of physostigmine is small, and serious side effects from overdose can occur as a result of excess cholinergic activity at neuromuscular synapses.

Flunitrazepam prevents succinylcholine-induced increase in intra-ocular pressure.

Ninety-three patients scheduled for various elective surgical procedures were divided into three equal groups and had induction of anaesthesia with either thiopentone (5 mg/kg), thiopentone (5 mg/kg) plus gallamine (0.3 mg/kg), or with flunitrazepam (0.03 mg/kg). Four minutes after induction they received a bolus intravenous injection of succinylcholine (1 mg/kg). Intra-ocular pressure was measured before and after induction, and approximately 1 minute after succinylcholine. It was found that flunitrazepam prevented the increase in intra-ocular pressure better than thiopentone plus gallamine. In both these groups, the subsequent intravenous administration of succinylcholine slightly increased the pressure but to levels below that noted before anaesthesia was induced. However, intra-ocular pressure was significantly increased above baseline levels when succinylcholine was injected after induction with thiopentone alone. Flunitrazepam is recommended, therefore, as a possible alternative for thiopentone-gallamine induction with succinylcholine when an increase in intra-ocular pressure must be prevented.

Oral flunitrazepam in the prevention of local anaesthetic-induced convulsions in mice.

The present study determined whether oral flunitrazepam was effective reducing CNS toxicity of lidocaine and bupivacaine. Pretreatment of mice with flunitrazepam, 0.065-0.25 mg X kg-1, significantly reduced or prevented convulsions and mortality induced by lidocaine 106 and 209 mg X kg-1 or bupivacaine 58 and 90 mg X kg-1 injected intraperitoneally. The doses of flunitrazepam used did not cause measurable sedation in mice. The efficacy of oral flunitrazepam in preventing local anaesthetic-induced convulsions is similar to that previously reported by intraperitoneal or intramuscular injections in mice. Flunitrazepam could be useful for oral premedication of patients before regional anaesthesia.

Common bile duct pressure in dogs after opiate injection--epidural versus intravenous route.

The effect on the common bile duct pressure of epidurally injected morphine and fentanyl, was compared with that of intravenous injections of the same drugs in 12 mongrel dogs. Intravenous injection of morphine (0.1 mg X kg-1) or fentanyl (0.01 mg X kg-1) significantly elevated the common bile duct pressure from 10.48 +/- 0.37 to 21.68 +/- 0.33 cm H2O and from 9.66 +/- 0.33 to 14.14 +/- 0.21 cm H2O respectively. These increases occurred within 4-15 minutes after injection and lasted for about 2-3 hours. When the narcotics in identical dosages were injected epidurally, the common bile duct pressures were unchanged during the four hours of investigation. Further studies are planned to determine whether this beneficial effect of epidural narcotics applies also in the human clinical situation.