Auditory function following post-dural puncture headache treated with epidural blood patch. A long-term follow-up.

BACKGROUND: Epidural analgesia is commonly used for pain management during labor. Sometimes, accidental dural puncture (ADP) occurs causing severely debilitating headache, which may be associated with transient hearing loss. We investigated if auditory function may be impaired several years after ADP treated with epidural blood patch (EBP). METHODS: Sixty women (ADP group) without documented hearing disability, who received EBP following ADP during labor between the years 2005-2011 were investigated in 2013 for auditory function using the following tests: otoscopic examination, tympanometry, pure tone audiometry, and transient-evoked otoacoustic emissions. Additionally, they responded to a questionnaire, the Speech, Spatial and Qualities (SSQ) of hearing, concerning perceived hearing impairment. The results were compared to a control group of 20 healthy, non-pregnant women in the same age group. RESULTS: The audiometric test battery was performed 5.2 (1.9) years after delivery. No significant differences were found between the ADP and the control groups in tympanometry or otoacoustic emissions. Pure tone audiometry revealed a significant but small (< 5 dB) difference between the ADP and control groups (P < 0.05). The ability to hear speech in noise as measured by SSQ was significantly reduced in the ADP group compared to the control group (P < 0.05). CONCLUSIONS: A minor hearing loss was detected in the ADP group compared to the control group in pure tone audiometry in some women and during speech-in-noise component several years after accidental dural puncture treated with an epidural blood patch. This small residual hearing loss has minor clinical significance.

Low dose intrathecal morphine effects on post-hysterectomy pain: a randomized placebo-controlled study.

BACKGROUND: Spinal anesthesia with different doses of intrathecal morphine has been shown to relieve post-operative pain. We studied in a prospective randomized, double-blind fashion the effects of morphine 0, 100, 200, or 300 µg added to intrathecal bupivacaine on first post-operative 24 h patient-controlled analgesia morphine (PCA-morphine) consumption after abdominal hysterectomy under general anesthesia. METHODS: One hundred and forty-four American Society of Anesthesiologists I-II women were assigned to receive spinal anesthesia with 12 mg of hyperbaric bupivacaine combined with 100, 200, and 300 µg morphine or saline before standardized general anesthesia was induced. Low transverse incision abdominal hysterectomy was performed. Post-operative outcome measures were recorded at 1, 2, 4, 6, 12, and 24 h. Primary outcome was 24 h PCA-morphine. Secondary outcomes were pain by visual analogue scale (0-10), nausea, pruritus, sedation, and respiratory depression. RESULTS: Intrathecal morphine reduced accumulated 24 h post-operative morphine consumption. Morphine 100 µg significantly reduced morphine consumption vs. placebo at 0-6 h, 6-12 h, and for the entire 0-24 h time interval post-operation. Morphine 200 µg further significantly reduced morphine consumption vs. morphine 100 µg at 0-6 h and for the entire 0-24 h post-operation. There was no further reduction of morphine consumption seen with morphine 300 µg. No serious side effects were seen. Emesis was similar in all groups, and pruritus was experienced only in the morphine groups. CONCLUSION: Intrathecal morphine supplementation to bupivacaine reduces first 24 h PCA-morphine consumption after abdominal hysterectomy under general anesthesia, and we found no benefit from increasing the dose over 200 µg.

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.

Prediction of hypotension during spinal anesthesia for Cesarean section and its relation to the effect of crystalloid or colloid preload.

BACKGROUND: If parturients prone to develop caval compression in the supine position were identified before delivery, this might be a method of predicting hypotension during caesarean section under spinal anesthesia. Colloid preloading is superior to crystalloid in reducing the risk for spinal anesthetic-induced hypotension. It is postulated that parturients preoperatively susceptible to the supine position would benefit the most from colloid preloading. METHODS: Fifty-five healthy parturients scheduled for elective cesarean section under spinal anesthesia were preoperatively investigated with a supine stress test with measurement of maternal heart rate, blood pressure, right uterine artery pulsatility index and symptoms in the left lateral and supine positions. They were then randomized to receive a colloid or crystalloid preload before anesthesia. RESULTS: The stress test was positive, indicating a reduced tolerance to the supine position, in 36%. The sensitivity and specificity of the stress test for clinically significant hypotension (symptomatic hypotension) for patients randomized to the crystalloid group (n=25) were 69 and 92% respectively. Patients with a positive stress test receiving a crystalloid preload showed a higher frequency of hypotension compared to all other groups, 90% vs. 33%, (P=0.003) and also a greater need for ephedrine, mean dose (SD): 20.0 (9.7) vs. 8.4 (9.0) mg (P=0.002). CONCLUSIONS: Pregnant women with a positive preoperative supine stress test constitute a subset at increased risk for clinically significant hypotension during cesarean delivery under spinal anesthesia. These women seem more likely to benefit from prophylactic colloid solution than women with a negative stress test.

Nausea and vomiting after laparoscopic gynecological surgery: a study of the incidence and the effects of tropisetron prophylaxis.

The authors studied the incidence of postoperative nausea and vomiting (PONV) and the effect of prophylactic tropisetron, a 5-HT3 antagonist, during the first 24 h following elective gynecologic laparoscopic surgery. Thirty-two of 68 (47%) of the patients experienced nausea or vomiting some time during the observation period. Sixteen of the 32 PONV patients (50%) had their first emetic symptoms after discharge from the recovery room. We could see no difference in the frequency of PONV in the patients who were given prophylactic tropisetron 5 mg orally before anesthesia.

Nausea and vomiting after laparoscopic gynecologic surgery: a study of the incidence and the effects of tropisetron prophylaxis.

We have studied the incidence of postoperative nausea and vomiting (PONV) and the effect of prophylactic tropisetron, a 5-HT3 antagonist, during the first 24 hr after elective gynecologic laparoscopic surgery. Thirty-two of 68 patients (47%) experienced nausea or vomiting some time during the observation period. Sixteen of these patients (50%) had their first emetic symptoms after discharge from the recovery room. We could see no difference in the frequency of PONV in the patients who were given prophylactic tropisetron 5 mg orally before anesthesia.

Successful EXIT (ex utero intrapartum treatment) procedure in a fetus diagnosed prenatally with congenital high-airway obstruction syndrome due to laryngeal atresia.

Congenital high-airway obstruction syndrome (CHAOS) is due to rare malformations and has been reported previously in only few cases. If the diagnosis can be made prenatally, the ex utero intrapartum treatment (EXIT) procedure may be life-saving. A healthy 28-year old nulli-para was referred because of isolated ascites found at gestational week 16 during routine ultrasound scan. Repeated scans showed overdistended hyperechogenic lungs with inverted diaphragm and a dilated trachea, which was interpreted as a CHAOS resulting from laryngeal atresia. The ascites eventually disappeared. An EXIT procedure was performed at 35 weeks of gestation. Anesthesia of the mother was induced with thiopental, succinylcholine and fentanyl followed by intubation, and maintained with isoflurane and nitrous oxide. A low abdominal midline incision was performed followed by a low transverse incision of the uterus. The fetal head, right arm and shoulder were delivered and intramuscular anesthesia was administered to the fetus. Immediate laryngoscopy confirmed the diagnosis and a tracheostomy was therefore performed. Surfactant was given after a few minutes of ventilation. Compliance improved and when the fetus was easy to ventilate, it was delivered. The baby is developing normally at 18 months of age. Surgical correction of the malformation will be performed after two years of age. It is concluded that some fetuses with a prenatal diagnosis of CHAOS can benefit from the EXIT procedure at delivery. This necessitates a multidisciplinary management team.

Neurological complications in obstetric regional anaesthesia.

Neurological complications after obstetric central neural blocks are rare events. Although central neural blockade does cause neurological complications, there must be awareness that neurological deficits may either develop spontaneously (e.g. epidural abscess/haematoma) or as a result of the labour and delivery process (maternal obstetric palsies). We have attempted to review as completely as possible the published survey and case reports in the English literature on neurological complications of obstetric regional blockade obtained from Medline spanning the period 1966 to November 1998. We also performed cross-checking of our references to find important missing articles, e.g. papers published in journals not included in Index Medicus at the time of publication, such as the International Journal of Obstetric Anesthesia. We wish to provide some insight to the incidences, pathophysiology, clinical features, investigations, treatment and prognosis of these complications. Maternal obstetric palsies and case reports of spontaneous epidural abscess/haematoma are also discussed. It is often difficult, if not impossible, to determine the exact aetiology, but unfortunately for the anaesthetists, regional blockade is usually incriminated till proven otherwise. Although we cannot eliminate the occurrence of neurological complications completely, preventive measures can still be taken to decrease their incidence (e.g. aseptic technique). There must also be regular monitoring after neural blockade for the development of neurological complications. Early diagnosis and prompt appropriate treatment will usually lead to complete resolution of the neurological deficit even in cases of epidural haematoma/abscess.

Four cases of the ex utero intrapartum treatment (EXIT) procedure: anesthetic implications.

The ex utero intrapartum treatment (EXIT) procedure is a method of maintaining utero-placental circulation during cesarean section to gain time to secure a potentially obstructed fetal airway. Four cases of the EXIT procedure are described with special reference to the maternal anesthetic technique. Deep volatile anesthesia (approximately 2 MAC) with isoflurane or sevoflurane for a prolonged period of time, in three cases in combination with an intravenous nitroglycerin infusion, was used to ensure a fully relaxed uterus during the procedure. All mothers were maintained hemodynamically stable with preserved utero-placentary perfusion. It was possible to intubate the tracheas of two fetuses, whereas in the other two tracheostomies had to be performed. Fetal gas exchange was not negatively affected during the EXIT procedure as evidenced by normal blood gas values in the umbilical artery at the time of delivery. After reducing the concentration of volatile anesthetic, delivery of the neonate and administration of oxytocin, uterine contractility was promptly re-established and there were no signs of uterine atony in the postoperative period. All four neonates survived the procedure without complications.

Strategies for equity in health: report from Sweden.

In recent years the Swedish debate on health policy has been focusing on resource allocation between primary care versus secondary care, private care versus public care, and prevention versus care. The National Commission on the "Swedish Health Services in the 1990s" brought attention to the prevailing inequalities in health. The Health Policy Bill of 1985 defines the reduction of inequalities in health as a major target of national health policy. The health policy measures discussed are mainly outside the health care sector.

Addition of low-dose morphine to intrathecal bupivacaine/sufentanil labour analgesia: A randomised controlled study.

BACKGROUND: Single-shot spinal analgesia with bupivacaine and a short-acting opioid for labour pain is popular due to its simplicity, rapid onset, and profound analgesia without significant motor block. Its limitation is the short duration of action. Supplementation with intrathecal morphine has been shown to prolong analgesia. We compared the addition of placebo or morphine 50 or 100 µg to intrathecal bupivacaine and sufentanil to evaluate the impact on duration of labour analgesia. METHOD: Following ethics committee approval and verbal and written patient consent, 90 healthy nulliparous women were included in the study. As part of a combined spinal-epidural technique, women were randomised to receive intrathecal bupivacaine 1.25mg and sufentanil 5 µg with morphine 50 µg, 100 µg or saline placebo in a double-blind fashion. Onset of analgesia was measured as the time from intrathecal injection to a visual analogue scale pain score < or =4 (scale 0-10) and the duration of analgesia as the time from intrathecal injection to the return of pain >4. RESULTS: No significant differences between the groups were seen in onset or duration of analgesia, side effects or obstetric and neonatal outcome. CONCLUSION: The addition of 50 or 100 µg morphine to 1.25mg bupivacaine and 5 µg sufentanil during established labour did not significantly increase the duration of analgesia.

Scandinavian Clinical Practice Guidelines on the diagnosis, management and follow-up of anaphylaxis during anaesthesia.

The present approach to the diagnosis, management and follow-up of anaphylaxis during anaesthesia varies in the Scandinavian countries. The main purpose of these Scandinavian Clinical Practice Guidelines is to increase the awareness about anaphylaxis during anaesthesia amongst anaesthesiologists. It is hoped that increased focus on the subject will lead to prompt diagnosis, rapid and correct treatment, and standardised management of patients with anaphylactic reactions during anaesthesia across Scandinavia. The recommendations are based on the best available evidence in the literature, which, owing to the rare and unforeseeable nature of anaphylaxis, mainly includes case series and expert opinion (grade of evidence IV and V). These guidelines include an overview of the epidemiology of anaphylactic reactions during anaesthesia. A treatment algorithm is suggested, with emphasis on the incremental titration of adrenaline (epinephrine) and fluid therapy as first-line treatment. Recommendations for primary and secondary follow-up are given, bearing in mind that there are variations in geography and resources in the different countries. A list of National Centres from which anaesthesiologists can seek advice concerning follow-up procedures is provided. In addition, an algorithm is included with advice on how to manage patients with previous suspected anaphylaxis during anaesthesia. Lastly, Appendix 2 provides an overview of the incidence, mechanisms and possibilities for follow-up for some common drug groups.

Colloid vs. crystalloid preloading to prevent maternal hypotension during spinal anesthesia for elective cesarean section.

BACKGROUND: Hypotension associated with spinal anesthesia for cesarean section is still a clinical problem. Colloid solutions seem preferable to crystalloid solutions for preloading. In most studies the overall rate of hypotension is reported. Few studies have, however, investigated the maternal and neonatal consequences of different levels of maternal hypotension. METHODS: In this randomized, double-blinded study 110 patients presenting for elective cesarean section received either 1000 ml acetated Ringer's solution or 1000 ml 3% dextran 60 solution immediately before spinal anesthesia. The effect on overall hypotension, clinically significant hypotension (hypotension associated with maternal discomfort defined as nausea, retching/vomiting, dizziness or chest symptoms) and severe hypotension (systolic arterial pressure <80 mmHg) was studied. RESULTS: Dextran reduced the incidence of overall hypotension from 85 to 66% (P=0.03), reduced the incidence of clinically significant hypotension from 60 to 30% (P=0.002) and reduced the incidence of severe hypotension from 23 to 3.6% (P=0.004) compared to Ringer's solution. There were neither differences in neonatal outcome between treatment groups nor between neonates grouped after severity of maternal hypotension. CONCLUSION: Clinically significant hypotension seems to be a more suitable outcome variable than overall hypotension. The protective effect of the colloid solution increased with increased severity of hypotension.

Strategies for health financing in Kenya--the difficult birth of a new policy.

The Kenyan Government has recently introduced a new strategy for health financing. The roles of the World Bank and US-AID in developing this strategy are reviewed in this article. Particular attention is paid to the fact that the government--under heavy pressure from the World Bank-partly had to accept a strategy generating less revenue and greater inequities than alternative strategies considered. At the same time the policy options assessed illustrate how the Kenyan Government managed to avoid public health services being transformed into semi private services primarily for middle and high income groups.

Changes in ejection fraction during induction of anesthesia with two different i.v. techniques.

Two intravenous induction techniques were compared with respect to changes in ejection fraction (EF) and central hemodynamics in 30 patients scheduled for coronary artery surgery. Left ventricular EF was measured with a collimated single crystal probe linked to a microcomputer, after injection of 200 MBq Tc 99 m HSA. Stroke volume index (SI) determined by thermodilution and EF were used to calculate left ventricular volume in end-systole and end-diastole. In 20 patients (Group I), anesthesia was induced with diazepam (94 micrograms x kg-1), thiopentone (3 mg x kg-1) and fentanyl (3 micrograms x kg-1). In 10 patients (Group II), fentanyl (30 micrograms x kg-1) was used for induction. In Group I, EF decreased from 0.43 to 0.26 at intubation, while systemic vascular resistance index (SVRI) showed an increase. Left ventricular volume decreased during induction of anesthesia except during intubation. In Group II, EF and left ventricular volume remained unchanged during the study period. SVRI showed no increase at intubation. No change in contractility was indicated from the relation between the end-systolic pressure and volume, in any of the groups.

Changes in left ventricular diameter during intravenous induction of anesthesia.

Transthoracic two-dimensional echocardiography was used to measure left ventricular diameter in end-systole and end-diastole during anesthetic induction in 11 patients before coronary artery bypass grafting. Midazolam, 0.1 mg/kg, and fentanyl, 6 to 10 micrograms/kg, were used followed by pancuronium, 0.1 mg/kg. Lidocaine, 1.5 mg/kg, was given topically in the airways before intubation. During induction of anesthesia there was a gradual decrease in diastolic diameter (preload) and in systolic diameter and pressure (afterload). The decrease in end-diastolic diameter from 4.6 cm to 3.9 cm indicated a decrease in preload, defined as end-diastolic volume, by approximately 34%. These results are in agreement with earlier findings using calculated ventricular volumes, based on the determination of either ejection fraction with radionuclide cardiography or stroke volume with thermodilution, during induction of anesthesia with thiopental, diazepam, fentanyl, and pancuronium.

Left ventricular end-systolic pressure estimated from measurements in a peripheral artery.

Aortic and radial arterial pressure measurements were compared after cannulation and before cardiopulmonary bypass in 26 patients scheduled for coronary artery bypass grafting. The radial artery blood pressure range was 89 to 147 mm Hg systolic and 44 to 75 mm Hg diastolic. A difference was found between the central and peripheral dicrotic notch pressures, the former being 7.9 +/- 2.7 (SD) mm Hg higher than the latter. When 8 mm Hg was added to the notch pressure measured in the radial artery to construct a calculated end-systolic pressure, there was good agreement with the centrally measured notch pressure. The mean difference was -0.15 mm Hg with a 95% confidence interval of -1.2 to 0.9 mm Hg. It was not possible to calculate peak systolic aortic pressure with the same accuracy from the systolic and diastolic pressure measurements in the radial artery. It is concluded that left ventricular end-systolic pressure measured as the aortic dicrotic notch pressure can be calculated from the dicrotic notch pressure in the radial artery with reasonable accuracy.