[Difficulties in the removal and rupture of a peridural catheter]. / Difficultés de retrait puis rupture d'un cathéter péridural.

A case of inability to remove an epidural catheter after vaginal delivery is reported. Surgical removal under general anaesthesia was attempted, but the catheter tip was sheared off inadvertently. Because the parturient was asymptomatic, it was decided to stop the operation and to leave the catheter tip into the epidural space. This complication is often related to excessive insertion of the catheter into the epidural space.

[Severe hypothermia associated with cesarean section under spinal anesthesia]. / Hypothermie sévère au décours de césariennes sous rachianesthésie.

Temperature monitoring and prevention of hypothermia are rarely used during spinal anaesthesia for caesarean section because hypothermia risk is considered very low. However, in same conditions, we observed two cases of severe hypothermia. We report these two cases and discuss the effects of spinal anaesthesia on thermoregulatory system. Hypothermia seems explained by the effects of perimedullar anaesthesia that decrease the shivering and the vasoconstriction thresholds. These effects are potentiated by morphinomimetic adjunction. At last, we recall prophylactics measures.

[Narcolepsy and epidural obstetrical analgesia ]. / Narcolepsie et analgésie péridurale obstétricale.

We report the case of a parturient with a history of narcolepsy that delivered under epidural anaesthesia without any complication. Patients with narcolepsy might be at risk of delayed recovery or of apneic episodes after general anaesthesia while narcolepsy-cataplexy fits might be more frequent during regional anaesthesia. Avoiding sedative premedication and continuing medical therapy on the day of surgery are recommended to avoid these complications.

Hospital policy for prevention of infection after neuraxial blocks in obstetrics.

Even though most regional anesthesia textbooks and articles about infectious complications associated with central neuraxial blocks underline the necessity of surgical asepsis, none offers a clear and precise procedure. This protocol is intended to reduce variability of practices, and is felt to be stringent enough to be effective and liberal enough to be fully implemented. Any person involved with the procedure must wear a cap and a new face mask. The patient also should wear a cap. The anesthesiologist, wearing his usual operating room clothing, must wash his hands with an antiseptic soap solution, dry them on a sterile towel and wear sterile gloves. The patient's back should be disinfected at least twice (alcohol-iodine, alcoholic solution of chlorhexidine or of povidone-iodine). Disposable equipment only must be used. Drugs must be prepared contemporaneously and in a sterile manner (collar of non-sterilized ampoules cleaned with alcohol). The solution is drawn up through the filter (contained in the epidural set) but injected after filter removal. Infusion of sterile mixtures is preferable to top-ups, which require frequent disconnections that may cause hub colonization. Manipulation of the hub of the catheter must be preceded both by antiseptic hand washing and by swabbing with sterilized gauze soaked with 70% alcohol. Catheter removal requires only antiseptic hand washing in most circumstances. Wearing mask and gloves and improving skin disinfection practices are believed to be the more important parts of this protocol.

[Calcification of thrombus associated with central venous catheter: unusual complication]. / Calcification d'un thrombus péricathéter veineux central: une complication exceptionnelle.

Thrombosis originating from the tip of central venous catheter is a well known complication. The calcification of such a thrombus is very rare. Until now, only two cases had been described with long-term indwelling central venous catheters used for total parenteral nutrition. We report the first case of a calcified thrombus occurred during a short-term central venous catheterisation. The presumptive mechanism of thrombus calcification is precipitation of calcium salts and its deposition on a pre-existent thrombus. In total parenteral nutrition the mechanism of calcification seems to be multifactorial. Thus, the precipitation of calcium phosphate is increased by the following factors: higher calcium and phosphate concentrations, the use of calcium chloride instead of calcium gluconate, lower pH solutions, slow infusion rate.

[Learning placement of a new oropharyngeal intubation (Copa)]. / Apprentissage de la mise en place d'une nouvelle canule oropharyngée (Copa).

OBJECTIVE: To assess learning of Copa (cuffed oropharyngeal airway) technique required for insertion and manual ventilation. STUDY DESIGN: Open prospective clinical study. PERSONS: Four staff members, two anaesthetists and two nurse anaesthetists and 74 ASA I or II patients without difficult intubation criteria presenting for minor surgery in the supine position under general anaesthesia. METHODS: After induction of anaesthesia, the Copa was inserted by each doctor and nurse in at least 16 patients and the ventilation manually assisted until spontaneous breathing resumed. RESULTS: The success rate of insertion at the first attempt was 97%. Therefore no learning period was required. Two laryngospasms and two episodes of cough occurred during Copa placement. Additional manipulations to optimise the ventilation were needed in 48 patients. CONCLUSION: Copa is easy to use without previous training. Further studies are required to assess its side effects and the appropriate depth of anaesthesia required for its insertion.

Epidural anaesthesia for caesarean delivery in triple and quadruple pregnancies.

BACKGROUND: Mechanical and/or hormonal factors may increase the spread of epidural anaesthesia in pregnancy, and hormonal changes are more pronounced in high-order pregnancies. However, no previous study has evaluated the dose requirements and haemodynamic effects of epidural anaesthesia for caesarean delivery in this latter situation. METHODS: The anaesthetic requirements to obtain a T4 upper sensory level were retrospectively compared in triple (n = 19) or quadruple (n = 2) pregnancies to 31 singleton pregnancies who received epidural anaesthesia for elective caesarean delivery using 2% lidocaine with 1/200,000 adrenaline. RESULTS: In high-order pregnancies, the gestational age at delivery was lower than in singleton pregnancies (34.9 +/- 1.9 weeks vs 38.2 +/- 1.1 weeks; P = 0.0001) whereas maternal body weight (76.5 +/- 8.7 kg vs 73.4 +/- 14.8 kg; NS) and lidocaine requirements (428 +/- 95 mg vs 426 +/- 98 mg; NS) were similar. Moreover, although the overall incidence of hypotension was not different (multiple pregnancy; 65% vs 58% in singletons), ephedrine (5.4 +/- 5.3 mg vs 10.7 +/- 13.8 mg; P < 0.05) and additional fluid requirements during onset of the block (4.3 +/- 1.7 mL/kg vs 5.3 +/- 2.6 mL/kg; P = 0.03) were less than in singletons. CONCLUSION: We found surprisingly similar anaesthetic requirements for epidural anaesthesia in high-order and singleton pregnancies. Mechanical factors may have played an important role. Moreover, the need for ephedrine and fluids was less in high-order pregnancies. This could be related to more pronounced physiological changes or to different physician attitudes.

The effect of adding a minidose of clonidine to intrathecal sufentanil for labor analgesia.

BACKGROUND: Preliminary studies have suggested that the addition of clonidine to intrathecal sufentanil prolongs analgesia without producing motor blockade. METHODS: Fifty-three nulliparous women in painful labor were included in this prospective, randomized, double-blinded study. Parturients at 2- to 5-cm cervical dilation received either 5 microg sufentanil plus 30 microg clonidine or 5 microg sufentanil intrathecally, followed by 5 mg bupivacaine epidurally. The primary outcome was time until first request for additional analgesia. Visual analog pain scores, sensory changes, blood pressure, heart rate, ephedrine requirements, motor blockade, sedation, pruritus, and nausea were also recorded. RESULTS: All parturients but one had effective analgesia in both groups, with similar sensory levels never exceeding T2. The duration (mean +/- SD) of analgesia was longer in the sufentanil-clonidine group: 125+/-46 versus 97+/-30 min (P = 0.007). The incidence of hypotension and the ephedrine requirements (median with range) were higher in the sufentanil-clonidine group: 63% versus 12% (P < 0.001) and 7.5 mg [range, 0-25.5 mg] versus 0 mg [range, 0-6 mg] (P < 0.0001). The incidence of fetal heart rate abnormalities during the first 30 min after intrathecal injection was similar in both groups (17% vs. 19%). No parturient had motor blockade. CONCLUSIONS: The addition of 30 microg clonidine to 5 microg intrathecal sufentanil extended the duration of labor analgesia without producing motor blockade. However, as previously reported with 100-200 microg clonidine, the incidence of hypotension and the ephedrine requirements were also increased, even when 30 microg clonidine only was added.

[Evaluation of training on intubation with a rigid fiber optic laryngoscope (UpsherScope)]. / Evaluation de l'apprentissage de l'intubation à l'aide d'un laryngoscope rigide à fibres optiques (UpsherScope).

OBJECTIVE: To evaluate the learning of tracheal intubation with a new rigid fibreoptic laryngoscope (UpsherScope). STUDY DESIGN: Open prospective study. PATIENTS: Five investigators used the UpsherScope to intubate the trachea in 164 patients scheduled for gynaecological surgery requiring tracheal intubation. All patients were of physical class ASA I or II and criteria for difficult intubation were negative. METHODS: After muscle relaxation, 120 seconds were allowed to intubate the trachea with the UpsherScope. If intubation had not been achieved by that time, the attempt was considered as a failure and the trachea was intubated using conventional laryngoscopy. RESULTS: The overall success rate with the UpsherScope was 73%. Forty-five tracheas could not be intubated with the device within 120 seconds. The inability to insert the tracheal tube through the vocal cords despite a good view of the larynx (23/45) or the inability to visualise the glottis because of secretions (21/45), were the two main causes of failure. CONCLUSION: The UpsherScope, a new rigid fibreoptic laryngoscope devised for routine and difficult intubation, is robust and allows the view of the tracheal tube passing between the vocal cords. However, in this study the intubation success rate remained low and was not improved by further experience. No benefit was found with the UpsherScope in patients with normal airways. Further studies are necessary to assess its efficiency in cases of difficult intubation.

Bacterial meningitis following combined spinal-epidural analgesia for labour.

We report a case of Streptococcus salivarius meningitis following combined spinal-epidural analgesia for labour. Although rare, bacterial meningitis following combined spinal-epidural anaesthesia is being increasingly described. We review the previously reported cases and discuss the possible aetiological causes and the aseptic precautions likely to reduce the incidence of infectious complications.

Intravenous nitroglycerin to relieve intrapartum fetal distress related to uterine hyperactivity: a prospective observational study.

During a 1-yr period, we evaluated prospectively the use of nitroglycerin (NTG) to relieve severe intrapartum fetal distress related to uterine hyperactivity. Sixty to ninety micrograms of NTG were injected intravenously (i.v.) within 2-5 min after onset of severe fetal distress after oxygen administration, left lateral decubitus, and discontinuation of any ongoing oxytocin infusion (62%) had failed to resolve the fetal heart rate abnormality. A second dose (60 or 90 micrograms) was used 2-3 min later as required. NTG was completely effective in 22 cases (fetal distress resolution within 4-5 min with restoration of normal uterine activity) and partially but sufficiently effective in the remaining 2 cases (fetal distress resolution within 4-5 min with residual mild uterine hyperactivity). However, a second dose was required for nine parturients (38%). Six parturients (25%) developed hypotension 2 min after the first NTG injection, with a mean nadir of 93.2 mm Hg (minimum 85 mm Hg). Hypotension was always rapidly reversed with a small single dose of ephedrine (4.5-6 mg). In conclusion, we found small doses (60-180 micrograms) of IV NTG to be associated with resolution of severe fetal distress related to uterine hyperactivity along with negligible side effects.

Maternal and fetal effects of adrenaline with bupivacaine (0.25%) for epidural analgesia during labour.

The use of adrenaline added to bupivacaine during epidural analgesia for labour is controversial. The effects of epidural analgesia with bupivacaine containing adrenaline on maternal blood pressure and heart rate, uterine activity, progress of labour, fetal heart rate and Apgar scores, were assessed using visual analogue pain scores, upper level of sensory block and motor blockade in 60 parturients who were allocated randomly to receive: 10 mL of bupivacaine 0.25% plain (group I) or with adrenaline 5 micrograms mL-1 (group II) or with adrenaline 1.66 micrograms mL-1 (group III). The first stage of labour was significantly longer in group II than in group I [414 +/- 49 vs. 296 +/- 24 min (+/- SD)]. There were no other significant differences. It is concluded that adrenaline at 5 micrograms mL-1 significantly prolongs the first stage of labour. Neither adrenaline 5 micrograms mL-1 nor 1.66 micrograms mL-1 has any beneficial effect.

Epidural analgesia for labour in a parturient with neurofibromatosis.

The first report of epidural analgesia for labour in a 26-yr-old woman with von Recklinghausen's neurofibromatosis is described. Epidural anaesthesia is often considered as contraindicated because neurofibromas may involve spinal cord and nerve roots. However, general anaesthesia was considered at high risk for this parturient on the basis of her previous medical and surgical history and of physical findings. The present observation suggests that epidural analgesia may be used in such circumstances provided that spinal cord neurofibromas have been ruled out by clinical and CT scan (or magnetic resonance imaging) examination.

[Accidental subdural extra-arachnoid catheterization during epidural analgesia in obstetrics]. / Cathétérisation accidentelle de l'espace sous-dural extra-arachnoïdien lors d'une analgésie péridurale en obstétrique.

The authors describe a case of accidental catheterization of the subdural extra-arachnoid space during epidural analgesia for labour. The epidural catheter had been inserted at the L3-L4 interspace without any problem. A severe hypotension occurred 90 min after the onset of analgesia. A T4 upper sensory level was associated with a complete motor blockade. Total spinal anaesthesia was suspected but ruled out because of delayed onset of analgesia. Extensive epidural anaesthesia was also eliminated as the local anaesthetic dose (15 mL of bupivacaine 0.125%) was not excessive for this patient. After delivery, a water-soluble contrast medium (10 mL of Omnipaque 180) was injected through the catheter and subsequent radiograph of spine showed subdural spread of the contrast medium. This complication might occur more frequently than usually thought and may be life-threatening. Anaesthetic management is discussed in the case of Caesarean section during labour.