Effect of sitting position on equal-dose spinal anaesthetic for caesarean section and post-partum tubal ligation.

BACKGROUND: We studied the hypothesis that an equal spinal anaesthetic dose administered in the sitting position to patients undergoing post-partum tubal ligation (PPTL) and caesarean section (CS) would yield similar sensory block characteristics and analgesic efficacy. METHODS: This prospective, non-randomised trial recruited 20 women undergoing PPTL within 48 h of vaginal delivery and 20 undergoing CS. Spinal anaesthesia comprising intrathecal hyperbaric bupivacaine 12 mg and morphine 100 µg was administered at L3/4 with patients sitting. Our primary end point was the maximal dermatomal sensory block (to cold). RESULTS: Baseline demographics were comparable, but PPTL patients had greater parity, with mean ± standard deviation 17.54 ± 11.2 h from delivery to spinal anaesthesia, and shorter duration of surgery, 17.54 ± 11.2 vs. 40.3 ± 15.5 min. Similar maximal sensory blocks (to cold) were achieved in group PPTL vs. CS, T4 (T1-T5) vs. T3 (T1-T5), P = 0.104, in comparable times, 8.6 ± 2.6 vs. 7.6 ± 3.0 min, P = 0.267. PPTL patients had significantly faster two-segment block regression (70.7 ± 23.5 vs. 97.6 ± 23.9 min, P = 0.001) and to T10 (120.8 ± 35.6 vs. 145.1 ± 24.3 min, P = 0.016), with less hypotension (25% vs. 65%, P = 0.025) and phenylephrine (20.0 ± 60.6 µg vs. 120.0 ± 119.6 µg, P = 0.005). CONCLUSION: The same dose of hyperbaric bupivacaine 12 mg and morphine 100 µg administered in the sitting position to both PPTL and CS parturients yielded similar maximal sensory blocks, but PPTL exhibited faster block regression and less hypotension/vasopressor requirement.

Ruptured uterine artery pseudoaneurysm: an overlooked cause of late postpartum haemorrhage.

We report an exceptional case of secondary postpartum hemorrhage (PPH) twenty days after cesarean delivery, resulting from a ruptured uterine artery pseudoaneurysm (UAP). The diagnosis was initially confounded by a septic shock necessitating inotropic support in the intensive care unit. Intense vaginal bleeding occurred eleven days after uterine curettage. Doppler ultrasound showed an anechoic focus in the inferior part of the uterus with turbulent flow. Bilateral internal iliac artery angiograms revealed a left uterine artery pseudoaneurysm that was successfully embolized. UAP is a rare cause of unexplained PPH that requires a high index of suspicion for diagnosis. This first report in the anesthesia literature serves to focus our awareness on its possible occurrence, and gives track to its management. Pitfalls in UAP diagnostic are highlighted (delayed presentation, possibility of spontaneous hemostasis, and lack of typical findings on colour Doppler sonography in hypotensive patients). These pitfalls may further be confounded by a concomitant sepsis. Angiography and selective uterine artery embolization is the treatment of choice.

Observations on the assessment and optimal use of videolaryngoscopes.

Due to the large number of videolaryngoscopes now available, it might be difficult for novice users to assess the various devices or use them optimally. We have collated the experiences of several airway management experts to assist in the assessment and optimal use of seven commonly used videolaryngoscopes. While all videolaryngoscopes have unique features, they can be broadly divided into those inserted via a midline approach over the tongue and those inserted laterally along the floor of the mouth. Videolaryngoscopes that are placed on the floor of the mouth displace the tongue antero-laterally and flatten the submandibular tissues. They generally require a conventional shaped bougie for tracheal intubation. Videolaryngoscopes that use the midline approach may have an in-built airway conduit for the tracheal tube or may require a 'J-shaped' stylet in the tracheal tube to negotiate the upper airway. This may cause difficulty when the tracheal tube is inserted through the glottis and the tip abuts the anterior wall of the subglottic space. Knowledge of the mechanism used by videolaryngoscopes to achieve laryngoscopy is essential for safe and successful tracheal intubation when using these devices.

Comparison of the LMA Supreme vs the i-gel in paralysed patients undergoing gynaecological laparoscopic surgery with controlled ventilation.

We compared the efficacy of the inflatable cuff of the LMA Supreme against the non-inflatable i-gel cuff in providing an adequate seal for laparoscopic surgery in the Trendelenburg position in 100 female patients. There was no difference in our primary outcome, oropharyngeal leak pressure, between the LMA Supreme and the i-gel (mean (SD) 26.4 (5.1) vs 25.0 (5.7) cmH(2) O, respectively; p = 0.18). Forty-seven (94%) LMA Supremes and 48 (96%) i-gels were successfully inserted on the first attempt, with similar ease, and comparable times to the first capnograph trace (mean (SD) 14.3 (4.7) s for the LMA Supreme vs 15.4 (8.2) s for the i-gel; p = 0.4). Gastric tube insertion was easier and achieved more quickly with the LMA Supreme vs the i-gel (9.0 (2.5) s vs 15.1 (7.3) s, respectively; p < 0.001). After creation of the pneumoperitoneum, there was a smaller difference between expired and inspired tidal volumes with the LMA Supreme (21.5 (15.2) ml) than with the i-gel (31.2 (23.5) ml; p = 0.009). There was blood on removal of two LMA Supremes and one i-gel. Four patients in the LMA Supreme group and one patient in the i-gel group experienced mild postoperative sore throat.

Comparison of three videolaryngoscopes: Pentax Airway Scope, C-MAC, Glidescope vs the Macintosh laryngoscope for tracheal intubation.

We compared the intubating characteristics of the Pentax Airway Scope, the C-MAC and the Glidescope with those of the Macintosh laryngoscope in 400 patients without predictors of difficult intubation. We found shorter intubation times with the Airway Scope (mean (SD) 20.6 (11.5) s) compared with the C-MAC (31.9 (17.6) s) and Glidescope (31.2 (15.0) s), p < 0.001. The median (IQR [range]) score for ease of intubation was significantly lower (better) with the Airway Scope (0 (0-8.75 [0-60])) than with the C-MAC (10 (0-20 [0-90])) or Glidescope (0 (0-20 [0-80])), p < 0.001. Ease of blade insertion in the C-MAC (0 (0-0 [0-30])) was superior to that of the Airway Scope (0 (0-0 [0-70])), Macintosh (0 (0-0 [0-80])) or Glidescope (0 (0-10 [0-60])), p = 0.006. More patients had a grade 1 laryngeal view with the Airway Scope (97%) compared with the C-MAC (87%), Glidescope (78%), or Macintosh (58%), p < 0.001. There were no grade 3 laryngeal views with the Airway Scope. The three videolaryngoscopes had comparable first attempt successful intubation rates: 95% for the Airway Scope, 93% for the C-MAC and 91% for the Glidescope.

A prospective, randomised, cross-over trial comparing the EndoFlex and standard tracheal tubes in patients with predicted easy intubation.

We aimed to determine if using the EndoFlex tracheal tube on the first intubation attempt provided improved placement times and intubation success compared with a standard-type tracheal tube in 50 patients undergoing gynaecological surgery in a prospective, randomised, cross-over trial. We found that using the EndoFlex resulted in shorter intubation times (mean (SD) 14.8 (9.7) vs 30.1 (30.5) s), easier intubation (VAS, median (range) 10 (0-70) vs 20 (0-100)), and an increased rate of successful insertion at the first attempt; all p < 0.001. Flexing the distal tip of the EndoFlex was used in 18 patients. There were reductions in the use of external laryngeal pressure, advancement of laryngoscope blade and increased lifting force when intubating with the EndoFlex. Furthermore, patients with a grade 2 (19/50) or 3 (6/50) laryngoscopic view had shorter intubation times, easier intubation and reduced insertion attempts with the EndoFlex. The EndoFlex is a satisfactory alternative to a standard-type tracheal tube, even with an anterior larynx.

Randomised comparison of Pentax AirwayScope and Glidescope for tracheal intubation in patients with normal airway anatomy.

SUMMARY: We compared intubating characteristics of the Pentax AirwayScope and Glidescope in a randomised controlled trial involving 140 patients. We found significantly shorter intubation times with mean (SD) 21.3 (12.3) vs 30.2 (13.2) s, lower intubating difficulty scores 4.4 (10.4) vs 12.8 (16.3) p < 0.001, and better grade 1 laryngeal views with the Pentax AirwayScope (95.7 vs 81.4%, p = 0.015). Significantly more optimisation manoeuvres were needed to successfully intubate with the Glidescope, with significant inability to align the tip of the tracheal tube with the glottic opening with the Glidescope in 9 (13%) vs no patients, p = 0.013. There was more mucosal bleeding (4 (5.7%) vs 1 (1.4%), p = 0.366), more lip bleeding (3 (4.3%) vs 1 (1.4%), p = 0.620) and significantly more postoperative sorethroat, 13 (18.6%) vs 0, p < 0.001 associated with the Glidescope.

Comparison of an equal-dose spinal anesthetic for cesarean section and for post partum tubal ligation.

BACKGROUND: We postulated that a spinal dose of hyperbaric bupivacaine 12 mg and morphine 100 microg administered for cesarean section would yield an equivalent sensory block height and provide sufficient analgesia if administered within 48 h of delivery for postpartum tubal ligation. METHOD: 20 women undergoing postpartum tubal ligation (PPTL) within 48 h of vaginal delivery and 20 undergoing cesarean section (CS) were recruited. Spinal anesthesia was induced with intrathecal hyperbaric bupivacaine 12 mg and morphine 100 microg at L3/4 with patients in the right lateral position. RESULTS: Baseline demographics of groups were comparable, but tubal ligation patients had greater parity, with a mean+/-SD 14.5+/-7.5 h from delivery to spinal anesthesia, and shorter duration of surgery, 21.4+/-7.6 vs. 35.3+/-11.3 min. Maximal sensory block was higher in group CS than PPTL, T2 (T1-T4) vs. T3 (T2-T5), P=0.001; time to reach maximal level did not differ significantly, (6.9+/-3.9 vs. 8.7+/-2.8 min, P=0.091). There was no difference in time for spinal block to recede two segments or to T10, and for motor block recovery to Bromage 2, all P>0.05. More CS patients were hypotensive (80% vs. 45%, P=0.048) and had intraoperative nausea (25% vs. 0%, P=0.047), but mean phenylephrine and ephedrine usage did not differ significantly. CONCLUSION: An equivalent dose of hyperbaric bupivacaine 12 mg and morphine 100 microg for both CS and PPTL resulted in a higher sensory block, more hypotension and nausea in CS patients. The studied regimen might be appropriate for PPTL, but appears excessive for CS.

Comparison of the single use and reusable intubating laryngeal mask airway.

We compared the times to intubate the trachea using the single use (Group S) and reusable (Group C) intubating laryngeal mask (ILMA(TM)), in 84 healthy patients with normal airways undergoing elective gynaecological surgery. There was no significant difference in the ease of insertion of the ILMA or the tracheal tube, or time to successful insertion (Group S, 101.4 s (SD 63.2) vs Group C, 90.4 s (SD 46.1), p = 0.366). The ILMA was successfully inserted on first attempt in 63% of Group S patients and in 68% of Group C patients. After one or two attempts the overall success rate for both groups was 93%. There was a failure to insert the ILMA in two patients in each group. There was no difference in side-effects (desaturation S(p)o(2) < 95%, bleeding, oesophageal intubation, lip, dental or mucosal injury, or sore throat postoperatively). We conclude that the disposable ILMA is an acceptable alternative to the reusable ILMA.

Comparison of the AMBU Laryngeal Mask and the LMA Classic in anaesthetised, spontaneously breathing patients.

There may be a role for single-use laryngeal mask airways with concerns about inability to adequately sterilise laryngeal mask airways to eradicate prion proteins. A single-blinded prospective randomised controlled trial was conducted to compare the clinical performance of the single-use AMBU LMA with the reuseable LMA Classic. There was no difference in time to insertion, successful insertion at first attempt, oropharyngeal leak pressure, haemodynamic response to insertion or complications of placement. The AMBU LMA was easier to insert. There was a suggestion of reduced postoperative sore throat and pharyngeal trauma for the AMBU LMA group. The AMBU LMA is a viable alternative to the LMA Classic for airway management in spontaneously breathing patients.

A randomised controlled trial on beneficial effects of early feeding post-Caesarean delivery under regional anaesthesia.

INTRODUCTION: We prospectively investigated the incidence of ileus, nausea/vomiting, and hospital course of non-labouring women fed immediately after Caesarean delivery under regional anaesthesia. METHODS: 196 patients were randomised into either the early-fed group (250 ml clear fruit juice 30 minutes postoperatively, and unlimited solid food thereafter) or the control group (clear feeds allowed after two hours, advanced to solids as tolerated). RESULTS: Both groups had similar baseline demographics and operative characteristics. Bowel sounds were present immediately postoperatively in 90.8 percent (early group) versus 95.9 percent (control). The early-fed group had reduced time to first drink (0.86 +/- 0.6 hours versus 14.4 +/- 18.2 hours) and solid food intake (4.2 +/- 2.7 hours versus 20.0 +/- 6.8 hours), earlier passage of flatus (14.4 +/- 9.4 hours versus 21.0 +/- 10.4 hours) and first stool (44.4 +/- 18.7 hours versus 65.6 +/- 25.4 hours), shorter duration of intravenous hydration (12.8 +/- 7.5 hours versus 22.4 +/- 5.8 hours), and earlier removal of intravenous cannulae (20.5 +/- 6.7 hours versus 24.7 +/- 7.8 hours), with all p-values less than 0.001. Early-fed mothers also mobilised (23.1 +/- 6.8 hours versus 27.4 +/- 7.6 hours), commenced breastfeeding (26.5 +/- 14.1 hours versus 38.8 +/- 21.8 hours), and were ready for discharge earlier (44.3 +/- 10.4 hours versus 62.0 +/- 12.7 hours), compared to the control group, with all p-values less than 0.001. There was no difference in mild ileus symptoms (3.1 percent). Earlier solid intake resulted in more nausea (10.2 percent versus 2 percent, p-value is 0.033), which was self-limiting. Maternal satisfaction rated higher in the early-fed group (90 versus 60, on visual analogue scale score 0-100, p-value is less than 0.001). CONCLUSION: This prospective randomised trial showed no increase in ileus with early feeding post-Caesarean delivery under spinal anaesthesia, with added benefits of earlier intravenous cannulae removal, ambulation, breastfeeding initiation and potential for shorter hospitalisation. Despite increased nausea in those taking solids earlier (but not feeds), maternal satisfaction rated higher in the early-fed group.

Comparison of the GlideScope video laryngoscope vs. the intubating laryngeal mask for females with normal airways.

BACKGROUND AND OBJECTIVE: In this randomized clinical study, we compared the intubation success rates of the intubating laryngeal mask airway with the GlideScope in patients with normal airways. The primary hypothesis was that the intubating laryngeal mask airway was equally effective as the GlideScope in terms of successful intubation times. METHODS: Sixty ASA I and II adult patients undergoing elective gynaecological surgery were randomly allocated into either the intubating laryngeal mask airway group or the GlideScope group. After a standard anaesthetic intravenous induction, orotracheal intubation was performed. Time taken for successful tracheal intubation, ease of device insertion, difficulty of tracheal intubation, manoeuvres needed to aid tracheal intubation, number of intubation attempts, haemodynamic changes every 2.5 min interval for 5 min and complications during tracheal intubation were recorded. RESULTS: Time to successful intubation was longer (mean 68.4 s +/- 23.5 vs. 35.7 s +/- 10.7; P < 0.05), mean difficulty score was higher (mean 16.7 +/- 16.3 vs. 7.3 +/- 13.1; P < 0.05) and more intubation attempts were required in the intubating laryngeal mask airway group. CONCLUSION: The GlideScope improved intubation time and difficulty score for tracheal intubation when compared with the intubating laryngeal mask airway in our patients. Blind intubation through the intubating laryngeal mask airway offers no advantages over the GlideScope in patients with normal airways. Despite its limitations, the intubating laryngeal mask airway is a valuable adjunct, especially in cases of difficult airway management when it can provide ventilation in between intubation attempts.

Ultra-low dose combined spinal-epidural anesthesia with intrathecal bupivacaine 3.75 mg for cesarean delivery: a randomized controlled trial.

BACKGROUND: We wished to investigate the feasibility of an ultra low-dose combined spinal-epidural technique in providing surgical anesthesia for uncomplicated cesarean deliveries in a randomized, double-blind controlled trial. METHOD: Forty-four normotensive, non-obese patients were randomized to receive either intrathecal hyperbaric bupivacaine 3.75 mg (low dose group, n=22) or 9 mg (conventional group, n=22), in addition to intrathecal fentanyl 25 microg, morphine 100 microg, and epidural 1.5% lidocaine 3 mL. Sensorimotor anesthesia and hemodynamic data were assessed at 2.5-min intervals for the first 15 min. RESULTS: The maximal sensory block achieved in the low-dose group was significantly lower than that in the conventional group (median T3, [range T2-T6] vs. T2 [C2-T6], P<0.001) with a longer time taken to reach maximal sensory block. The low-dose group had less motor block, faster sensory regression to T10 dermatome and faster motor recovery to Bromage 0 (all P<0.001). The block failed to reach T6 bilaterally within 10 min in one patient in the low-dose group and two in the conventional group, with no significant difference in the need for epidural supplementation before or after delivery of the baby. The low-dose group experienced less hypotension (14% vs. 73%, P<0.001) with less ephedrine usage (0.68 vs. 17.5 mg, P<0.001). There was no difference in operating conditions and other side effects (shivering, pruritus). CONCLUSION: We conclude that this technique results in a significantly lower incidence of maternal hypotension and has a role in high-risk parturients in whom maintenance of stable hemodynamics is imperative.