'Walking epidural': comparison of the analgesic efficacy of levobupivacaine 0.0625% + fentanyl 2mcg/mL versus ropivacaine 0.075% + fentanyl 2mcg/mL.

INTRODUCTION: Epidural infusion with low local anesthetic concentrations with opiates decrease the severity of the motor blockade associated. The present study aims to compare the analgesic efficacy and the motor blockade between two local anesthetic epidural infusions: levobupivacaine 0.0625% + fentanyl 2mcg/mL versus ropivacaine 0.075% + fentanyl 2mcg/mL. MATERIALS AND METHODS: In a single-blind prospective randomized study, 60 laboring parturient had continuous epidural analgesia as follows: 30 of them received levobupivacaine 0.0625% + fentanyl 2mcg/mL and 30 of them received ropivacaine 0.075% + fentanyl 2mcg/mL and rates of infusion were adjusted to the height. Analgesic, motor blockade and satisfaction records were collected as well as maternal and neonate adverse events. RESULTS: After 2 h of the catheter placement, patients who received levobupivacaine showed a mean VAS of 3.2 [1.8-4.6] versus 1.8 [1.2-2.5] (p = 0.05) in patients who received ropivacaine. In addition, patients who received levobupivacaine showed a punctuation in Bromage scale of 0.0 [0.0-1.0] versus 0.0 [0.0-0.0] (p = 0.04) in patients who received ropivacaine. Finally, the parturient who received levobupivacaine scored a mean satisfaction index of 8.1 [7.3-8.9] versus 9.3 [8.7-9.8] (p = 0.02) in those who received ropivacaine. We did not register maternal nor neonate adverse events. CONCLUSION: Both infusions (levobupivacaine 0.0625% + fentanyl 2mcg/mL and ropivacaine 0.075% + fentanyl 2mcg/mL) are effective for labor analgesia. However, ropivacaine would present a better pharmacodynamic profile with less motor blockade and decreased need for analgesic rescue hence improving patient's satisfaction.

Efficacy of "optimal hydration" during labor: HYDRATA study protocol for a randomized clinical trial.

There is a lack of consensus in the international scientific community with respect to the most suitable hydration strategies when attending nulliparous women during low-risk births. This paper describes the protocol for a randomized controlled trial to compare two hydration strategies and their influence on maternal and neonatal morbidity. The study population consists of nulliparous women admitted to the obstetrics department of a University Hospital. The women are being randomized into two groups: the "optimal hydration" group, which will be guaranteed 300 ml/hr liquids (crystalloids and bottled mineral water) with a minimum diuresis of 35 ml/hr; and the "variability in hydration" group, which will receive intravenous (alternating normal saline, Ringer's lactate solution, glucose, or Voluven®) and clear (bottled mineral water or isotonic drinks [Aquarius®]) liquids, without any established perfusion rate, and without established minimum diuresis. Outcomes for mothers include duration of labor, cesarean section, fever, and dehydration. Outcomes for newborns are respiratory distress, hypoglycemia, hyponatremia, jaundice, weight loss over 48 hr, and breastfeeding difficulties. Analysis will be per-protocol. Administering optimal hydration may improve health and safety for mothers and their newborn and reduce maternal and neonatal morbidity. The study is registered at www.clinicaltrials.gov. The project received funding by the Ministry of Health of Spain and is approved by the Research Ethics Committee.

Hemophilia C management in obstetric anesthesia.

Coagulation alterations might represent a problem in obstetric anesthesia considering that they may contraindicate neuraxial techniques and worsen a case of uterine atony with more severe bleeding if they are not correctly recognized and treated. We report the case of a parturient diagnosed with severe factor XI deficiency during the delivery progress. In this case, non-steroidal anti-inflammatory drugs and neuraxial techniques were avoided and intravenous patient-controlled analgesia with boluses of remifentanil was used for pain management. Treatment with tranexamic acid and fresh frozen plasma was initiated and the absence of urgent factor XI availability was notified. Due to no progression of labor, cesarean section was required and a general anesthesia was performed. During the procedure, uterine atony occurred. Uterine massage and several uterotonic drugs were needed to control it. The patient remained stable and the delivery was accomplished without further incidents. The objective of this report is to present the pain, coagulation and bleeding management of a patient with hemophilia C in our obstetric department and to alert for the need of multidisciplinary work to successfully approach this type of patient.

Buprenorphine versus dexamethasone as perineural adjuvants in femoral and adductor canal nerve blocks for total knee arthroplasty: a randomized, non-inferiority clinical trial.

BACKGROUND: Optimal control of acute postoperative pain and prevention of chronic persistent pain in total knee arthroplasty (TKA) remain a challenge. METHODS: A randomized, non-inferiority clinical trial (385 patients) evaluated every hour immediate postoperative pain during 24 h, using a verbal rating 11-point scale for patient self-reporting of pain (VRS11). All patients received subarachnoid anesthesia and were randomly allocated in four groups: single shots femoral (FNB) or adductor canal blocks (ACB), both with dexamethasone (dex) and buprenorphine (bup). Patients received intravenous analgesia (metamizole magnesium, dexketoprofen) and rescue analgesia when needed: intravenous (paracetamol and morphine) and/or regional (femoral and sciatic nerve blocks). Demographics and adverse effects were also recorded. RESULTS: A 45.7% of patients had pain: bupACB 56.3%, bupFNB 50.0%, dexACB 40.6% and dexFNB 36.1% (P=0.022). Rescue analgesia was needed in 37.7% of patients (P=0.128). There were statistical differences in percentage of timepoints without pain (95.0±7.9%, P=0.014) and mean VRS11 (0.18±0.3, P=0.012) but no differences in distribution of intensity periods of pain. There were no significant differences in the need of rescue analgesia excepting the use of intravenous morphine (P=0.025). CONCLUSIONS: Buprenorphine is in the present trial inferior to dexamethasone by less than the established non-inferiority limit when used as perineural adjuvant in femoral nerve or adductor canal blocks in total knee arthroplasty analgesia. So, it could be considered an alternative in patients where dexamethasone is contraindicated, such as diabetics.

A randomized clinical trial comparing six techniques of postoperative analgesia for elective total hip arthroplasty under subarachnoid anesthesia with opioids.

BACKGROUND: Optimal control of acute postoperative pain and prevention of chronic persistent pain in total hip arthroplasty (THA) remain a challenge. The main hypothesis was that peripheral nerve blocks improve postoperative analgesia. METHODS: Immediate postoperative pain (24 hours) was evaluated every hour in 510 patients using a verbal rating 11-point scale for patient self-reporting of pain (VRS-11). All patients received subarachnoid anesthesia (SA) and were randomly allocated in six groups: SA with morphine 0.1 (SA0.1) or 0.2 mg (SA0.2), fascia iliaca compartment block with dexamethasone 4 mg + levobupivacaine 0.375% 20 (FICB20) or 30 mL (FICB30), lateral femoral cutaneous nerve block with levobupivacaine 0.25% 5 mL (LFCNB) and FICB20+LFCNB. Standardized analgesia included intravenous metamizole magnesium, dexketoprofen and rescue with paracetamol and morphine, and/or regional rescue (FICB, LFCNB, femoral and sciatic nerve blocks). RESULTS: About 37.5% of patients had at least one episode of pain, 31.3% of them needed rescue analgesia while the remaining 6.2% did not request analgesia. There were no significant differences between the groups in paracetamol, morphine and rescue nerve blocks requirements. There was pain only in 5.4% of the total PACU pain records: 3.1% mild pain, 1.7% moderate pain and 0.6% severe pain. CONCLUSIONS: combined with a multimodal analgesic approach, infra-inguinal FICB and LFCNB did not improve immediate postoperative analgesia for THA in our hospital. Other options and longer-term studies should be more extensively investigated to determine the role of peripheral blocks in postoperative pain treatment protocols.

Reducing by 50% the incidence of maternal hypotension during elective caesarean delivery under spinal anesthesia: Effect of prophylactic ondansetron and/or continuous infusion of phenylephrine - a double-blind, randomized, placebo controlled trial.

BACKGROUND: Prophylactic administrations of ondansetron or phenylephrine have been reported to provide a protective effect against hypotension in women undergoing cesarean delivery under spinal anesthesia (SA). The main hypothesis is that ondansetron improves the hemodynamic response, especially combined with phenylephrine infusion. METHODS: This prospective, double-blind, randomized, placebo-controlled study included 265 healthy pregnant women scheduled for elective cesarean delivery under SA. Women were randomly allocated into four groups to receive either placebo (control), ondansetron (O) 8 mg intravenously before induction of SA, phenylephrine infusion (50 mcg/min) (P) or ondansetron plus phenylephrine (OP). Demographic, obstetric, intraoperative timing, and anesthetic variables were assessed at 16 time points. Anesthetic variables assessed included blood pressure, heart rate, oxygen saturation, nausea, vomiting, electrocardiographic changes, skin flushing, discomfort or pruritus, and vasopressor requirements. RESULTS: There were differences (P = 0.0001) in the number of patients with hypotension (50.8% control, 44.6% O, 20.9% P, 25.0% OP), the percentage of time points (P = 0.0001) with systolic hypotension per patient (17.4% control, 8.7% O, 2.1% P, 6.7% OP) and the number of patients requiring supplementary boluses of ephedrine (P = 0.003), phenylephrine (P = 0.017) or atropine (P = 0.0001). CONCLUSIONS: A 50 µg/min phenylephrine infusion reduces by 50%, the incidence of maternal hypotension compared with placebo, but infusions of phenylephrine are still not routine in our environment. Prophylactic ondansetron 8 mg might be considered in this situation, because it does not reduce the incidence of maternal hypotension but diminishes its severity, reducing the number of hypotensive events per patient by 50%.

Postoperative analgesia for elective total knee arthroplasty under subarachnoid anesthesia with opioids: comparison between epidural, femoral block and adductor canal block techniques (with and without perineural adjuvants). A prospective, randomized, clinical trial.

BACKGROUND: Optimal control of acute postoperative pain and prevention of chronic persistent pain in total knee arthroplasty (TKA) remain a challenge. The main hypothesis was that nerve blocks improve postoperative analgesia especially if perineural adjuvants are added. METHODS: Immediate postoperative pain (24 hours) was evaluated every hour in 639 patients using a verbal rating 11-point scale for patient self-reporting of pain (VRS-11). All patients received subarachnoid anesthesia and were randomly allocated in 8 groups: control group, epidural (EA) and single shots femoral (FNB) or adductor canal blocks (ACB), both with and without adjuvants: dexamethasone (+Dexa) or dexmedetomidine (+Dexm). Patients received intravenous analgesia (metamizole magnesium, dexketoprofen) and rescue analgesia when needed, intravenous (paracetamol and morphine) and/or regional (epidural boluses, femoral and sciatic nerve blocks). Demographics, orthopedic knee scores and adverse effects were also recorded. RESULTS: A 45.2% of patients had no immediate postoperative pain (P=0.0001). Rescue analgesia was needed in 48.8% of patients (P=0.0001): control group 72.8% of patients, EA 51.9%, FNB 40.0%, FNB+Dexa 33.3%, BNF+Dexm 41.3%, ACB 51.9%, ACB+Dexa 38.3% and ACB+Dexm 61.5% respectively. There were also differences in the total postoperative time without pain (P=0.0001), with mild (P=0.0001) or moderate pain (P=0.001) but not with severe pain (P=0.119). CONCLUSIONS: Peripheral nerve blocks with perineural dexamethasone improve postoperative analgesia for TKA. The addition of dexamethasone to adductor canal block open new possibilities to improve analgesia for TKA, and should be investigated as an alternative to femoral nerve block.