Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey.

BACKGROUND: a major risk with epidural analgesia is accidental dural puncture (ADP), which may result in post-dural puncture headache (PDPH). This survey was conducted to explore the incidence of ADP, the policy for management of PDPH and the educational practices in epidural analgesia during labour in the Nordic countries. METHODS: a postal questionnaire was sent to the anaesthesiologist responsible for Obstetric anaesthesia service in all maternity units (n=153) with questions relating to the year 2008. RESULTS: the overall response rate was 93%. About 32% (22-47%) of parturients received epidural analgesia for labour. There were databases for registering obstetric epidural complications in 13% of Danish, 24% of Norwegian and Swedish, 43% of Finnish and 100% of hospitals in Iceland. The estimated incidence of ADP was 1% (n approximately 900). Epidural blood patch (EBP) was performed in 86% (n≈780) of the parturients. The most common time interval from diagnosis to performing EBP was 24-48 h. The success rate for EBP was >75% in 67% (62-79%) of hospitals. The use of diagnostic CT/MRI before the first or the second EBP was exceptional. No major complication was reported. Teaching of epidurals was commonest (86%) in the non-obstetric population and 53% hospitals desired a formal training programme in obstetric analgesia. CONCLUSION: we found the incidence of ADP to be approximately 1%. EBP was the commonest method used for its management, and the success rate was high in most hospitals. Formal training in epidural analgesia was absent in most countries and trainees first performed it in the non-obstetric population.

Interaction of ketamine with atracurium.

The effect of ketamine on the duration of atracurium-induced neuromuscular blockade was studied in 40 healthy patients anaesthetized with midazolam, fentanyl and nitrous oxide. Twenty received, in addition, i.v. ketamine 2 mg kg-1 followed by an infusion of 2 mg kg-1 h-1. Atracurium 0.5 mg kg-1 was injected i.v. and the time to 25% recovery of the twitch height was measured. It was 8.0 min longer in the ketamine group (P less than 0.005), with a 95% confidence interval of from 2.3 to 11.8 min.

The influence of alfentanil on the intubating conditions after priming with vecuronium.

The ability of alfentanil 15 micrograms kg-1 or 30 micrograms kg-1 to improve intubating conditions was studied in four groups of 25 ASA class 1 patients. Induction of anaesthesia was with thiopentone 5 mg kg-1. Neuromuscular blockade was induced with vecuronium using the priming principle. The priming dose, priming interval and intubating dose were 0.01 mg kg-1, 4 min, and 0.1 mg kg-1, respectively. Intubation was attempted 1 min after the intubating dose. Intubating conditions were judged unacceptable in about 30% of the patients belonging to the control groups. Alfentanil 15 micrograms kg-1, when administered 65 s before intubation, reduced the incidence of coughing and diaphragmatic movement (P less than 0.05) but did not reduce the incidence of overall unacceptable intubating conditions. Alfentanil 30 micrograms kg-1, however, reduced the incidence of vocal cord movement (P less than 0.005) as well as coughing and diaphragmatic movement (P less than 0.002). Alfentanil 30 micrograms kg-1 reduced the incidence of unacceptable intubating conditions from about 30% to 4% (P less than 0.02).

The reduction of pain on injection of propofol: the effect of addition of lignocaine.

The effects of addition of 1 ml of lignocaine (10 mg) or isotonic saline to 19 ml of the emulsified preparation of propofol (Diprivan) were studied in a randomised, double-blind trial in 80 patients. The incidence and severity of pain on injection of propofol were significantly reduced by the addition of lignocaine (P less than 0.01).

Subarachnoid versus epidural bupivacaine 0.5% for caesarean section.

In order to compare subarachnoid (spinal) and epidural block for caesarean section, 40 women were randomly allocated to spinal or epidural analgesia with bupivacaine. The median dose of bupivacaine was 13 mg in the spinal group versus 155 mg in the epidural group. The mean time from induction to delivery was 32 min shorter in the spinal group (P less than 0.001). In the spinal group one woman was excluded because of spontaneous labour. Three patients in the spinal and one in the epidural group failed to develop adequate analgesia to initiate surgery. For the remaining patients both techniques provided good analgesia during operation. Postoperatively, epidural block provided better pain relief. The patients in the epidural group had a lower pain score during the first 4 h after the operation (P less than 0.01). In spite of similar haemodynamic changes in the two groups, the mean base deficit in umbilical cord blood at delivery was higher in the spinal group (P less than 0.05).

Oral or nasal intubation after cardiac surgery? A comparison of effects on heart rate, blood pressure and sedation requirements.

The aim of this study was to observe the effects of the position of the tracheal tube on cardiac performance or sedation requirements after cardiac surgery. There were no significant differences in heart rate, systolic blood pressure, or rate-pressure product during the first 16 hours postoperatively when 41 orally intubated patients were compared with 32 patients who were reintubated nasally. The two groups received similar amounts of sedative drugs postoperatively. During attempted nasal intubation, bleeding developed in four patients, and in three of these and four others the tube could not be passed. Failed nasal intubation gave rise to nasal discomfort in three of seven patients. Orally intubated patients complained more often of sore throat after extubation, whereas those who had been nasally intubated complained of discomfort in the nose and throat. We conclude that nasal re-intubation carries no advantage over oral intubation for ventilation after cardiac surgery.

Clonidine and the sympatico-adrenal response to coronary artery by-pass surgery.

Clonidine was administered intravenously in an attempt to limit sympatico-adrenal activity and thereby reduce the incidence of arterial hypertension associated with coronary artery by-pass graft surgery (CABG). Forty patients scheduled for CABG were assigned to two groups. Twenty patients received clonidine 4 micrograms kg-1 before surgery, 2 micrograms kg-1 after cardiopulmonary by-pass and 1 microgram kg-1 when the skin was sutured. The other 20 patients served as controls. All patients were anesthetized with fentanyl, droperidol, nitrous oxide and alcuronium. During surgery 5 min after sternotomy, mean arterial pressure was 13 mmHg lower (P less than 0.01) in the clonidine group, while after operation the difference between the groups was negligible. Both during and after surgery the plasma catecholamine concentrations were significantly lower in the clonidine group (P less than 0.01). The greatest difference between the groups was seen 90 min after operation, when plasma noradrenaline and plasma adrenaline concentrations in the clonidine group were less than 1/3 of those in the control group (P less than 0.01). As judged by catecholamine concentrations clonidine was effective in attenuating sympatico-adrenal hyperactivity during and after surgery. Postoperative arterial hypertension was not reduced, however, and it is concluded that other factors besides sympatico-adrenal hyperactivity must be important.