A randomized, double-masked, multicenter comparison of the safety of continuous intrathecal labor analgesia using a 28-gauge catheter versus continuous epidural labor analgesia.

BACKGROUND: Continuous intrathecal labor analgesia produces rapid analgesia or anesthesia and allows substantial flexibility in medication choice. The US Food and Drug Administration, in 1992, removed intrathecal microcatheters (27-32 gauge) from clinical use after reports of neurologic injury in nonobstetric patients. This study examined the safety and efficacy of a 28-gauge intrathecal catheter for labor analgesia in a prospective, randomized, multicenter trial. METHODS: Laboring patients were randomly assigned to continuous intrathecal analgesia with a 28-gauge catheter (n = 329) or continuous epidural analgesia with a 20-gauge catheter (n = 100), using bupivacaine and sufentanil. The primary outcome was the incidence of neurologic complications, as determined by masked neurologic examinations at 24 and 48 h postpartum, plus telephone follow-up at 7-10 and 30 days after delivery. The secondary outcomes included adequacy of labor analgesia, maternal satisfaction, and neonatal status. RESULTS: No patient had a permanent neurologic change. The continuous intrathecal analgesia patients had better early analgesia, less motor blockade, more pruritus, and higher maternal satisfaction with pain relief at 24 h postpartum. The intrathecal catheter was significantly more difficult to remove. There were no significant differences between the two groups in neonatal status, post-dural puncture headache, hemodynamic stability, or obstetric outcomes. CONCLUSIONS: Providing intrathecal labor analgesia with sufentanil and bupivacaine via a 28-gauge catheter has an incidence of neurologic complication less than 1%, and produces better initial pain relief and higher maternal satisfaction, but is associated with more technical difficulties and catheter failures compared with epidural analgesia.

Intrathecal hyperbaric bupivacaine dose response in postpartum tubal ligation patients.

BACKGROUND AND OBJECTIVES: Because of its short duration, hyperbaric lidocaine has been a popular intrathecal drug to provide anesthesia for postpartum tubal ligation (PPTL). However, reports of transient symptoms associated with its use have prompted the search for alternative intrathecal local anesthetics for short procedures. Hyperbaric bupivacaine is rarely associated with transient neurologic symptoms, and we designed this study to determine the optimal dose of bupivacaine for PPTL that assures adequate sensory block and allows the patient the shortest recovery time. METHODS: Forty American Society of Anesthesiologists (ASA) I-II patients undergoing spinal anesthesia for PPTL were randomly assigned to receive 5.0, 7.5, 10.0, or 12.5 mg hyperbaric bupivacaine in the right lateral position. RESULTS: Despite sensory block above T-8 in all groups, 4 of the 5 patients in the 5-mg group developed blocks insufficiently dense for surgery and required general anesthesia. Failed spinals occurred evenly in the remaining groups. Motor regression was significantly more rapid with decreasing doses of bupivacaine. Time in the postanesthesia care unit (PACU) was shorter in the 7.5-mg group. CONCLUSIONS: Hyperbaric bupivacaine 7.5 mg injected in the lateral position provides adequate surgical anesthesia for PPTL with a minimal duration of motor block and recovery time.

Choosing wisely in anesthesiology: the gap between evidence and practice.

To develop a "top-five" list of unnecessary medical services in anesthesiology, we undertook a multistep survey of anesthesiologists, most of whom were in academic practice, and a consequent iterative process with the committees of the American Society of Anesthesiologists. We generated a list of 18 low-value perioperative activities from American Society of Anesthesiologists practice parameters and the literature. Starting with this list and proceeding with a 2-step survey using a 5-point Likert scale questionnaire, we eventually identified 5 common activities that are of low quality or benefit and high cost and have poor evidence supporting their use. The 2 preoperative practices in the top-five list addressed the avoidance of unindicated baseline laboratory studies or diagnostic cardiac stress testing. The 3 intraoperative practices involved the avoidance of the routine use of the pulmonary artery for cardiac surgery and the use of packed red blood cells or colloid when not indicated.

Using heart rate variability to stratify risk of obstetric patients undergoing spinal anesthesia.

In this study, we evaluated whether point correlation dimension (PD2), a measure of heart rate variability, can predict hypotension accompanying spinal anesthesia for cesarean delivery. After the administration of spinal anesthesia with bupivacaine, hypotension was defined as systolic blood pressure