The concordance rate of L3/4 intervertebral lumbar level estimated by palpation and ultrasonography in Japanese parturients.

Background: The accurate identification of an intervertebral lumbar level is essential to avoid neuraxial anesthesia and analgesia-related spinal cord injury. It has been shown that estimation of L3/4 intervertebral lumbar level based on the intercristal line determined by palpation (palpated L3/4) is often inaccurate. However; studies evaluating intervertebral lumbar level concordance based on palpation vs. ultrasonography were conducted in Western populations (i.e. in North America and/or Europe). Radiological studies suggest that the intercristal line intersects at a lower level of the spine in Japanese women than in Western women. Therefore, we hypothesized that differences exist in intervertebral levels based on the palpated intercristal line between Asian and Western women. Herein we present the results of the first study in Japan comparing the concordance rate of L3/4 intervertebral lumbar level estimated by palpation and ultrasonography in pregnant Japanese women.Study objective: The objective of this study was to evaluate the accuracy of palpated L3/4 in Japanese parturients assessed by ultrasonography (US).Design: A prospective, observer-blinded study.Setting: Labor and delivery room at the Kitasato University Hospital, Sagamihara, Kanagawa, Japan.Patients: Sixty-three term parturients underwent induction of labor and requested neuraxial labor analgesia.Interventions: With the patients in the sitting position, an attending anesthesiologist marked the intervertebral space estimated as L3/4 based on intercristal line with palpation. Another attending anesthesiologist who was blinded to the marker performed US to identify L3/4.Results: The overall agreement rate of palpated and US L3/4 was 69.8% (44/63). Palpated L3/4 was US L2/3 in 8/63 (12.7%) and US L4/5 in 11/63 (17.5%). In comparison with women with palpated L3/4 agreed with US L3/4, women with palpated L3/4 agreed with US L2/3 were more frequently multiparous (52 vs. 100%, p < .05) and women with palpated L3/4 identified as L4/5 were younger (36 ± 4 years vs. 33 ± 4 yrs, p < .05) and gained less weight during pregnancy (10 ± 4 kg vs. 7 ± 4 kg, p < .05). The patients whose palpated L3/4 were found to be US L2/3 were all multiparous.Conclusion: The accuracy rate of palpated L3/4 intervertebral lumbar level in pregnant women included in our study was 69.8%. Pregnancy-related weight gain, parity, and maternal age can all influence an estimation of L3/4 intervertebral lumbar level by palpation. In addition, we believe that this is the first study to analyze the correlation between maternal parity and interspace estimation by palpation in pregnant women.

Comparison of sevoflurane administered through a face mask versus rectal thiopental sodium in children undergoing magnetic resonance imaging.

OBJECTIVE: Sevoflurane (S) and thiopental sodium (T) are commonly used to produce sedation for routine MRI procedures. However, to date there have been no comparative studies evaluating both techniques. We herein present the firt study comparing S and T techniques for pediatric sedation in MRI procedures. MATERIALS AND METHODS: 21 children, aged from 3 months to 6 years, scheduled for MRI were randomly assigned to either S or T group. Sedation performed under spontaneous respiration was induced with inspired 1-8% S in oxigen by face mask connected to a Mapleson C circuit or T (25 mg/kg) administered in distal rectum by cannula. The observed parameters included: time for induction, MRI time, first movement activity postprocedure and recovery time; MRI pauses from patient movement; technique failure, quality of the study, emergence agitation, critical events; and parental and radiologist satisfaction. RESULTS: S compared with T showed significantly shorter anesthesia induction time (1.93 ± 0.7 versus 13.5 ± 2.6 min), first movement time (3.38 ± 1.2 versus 5.9 ± 2.1 min), recovery time (6.8 ± 1.6 versus 10.14 ± 3.3 min), and discharge MRI time (27.83 ± 5.1 versus 47.5 ± 8.7 min). There were fewer pauses during MRI from patient movement in S versus T (0 versus 3). The radiologists reported good quality and satisfaction scores in both groups. There were less behavioral disturbances in T group compared with S group (1 versus 3). There were no critical events in either group. There were no differences in parental satisfaction in both groups. CONCLUSIONS: Sevoflurane shortens the induction and recovery time, enabling earlier discharge. Sevoflurane and rectal thiopental sodium protocols are safe and effective, providing adequate conditions for MRI in pediatric outpatients, although rectal thiopental is more unpredictable.

A review of current anesthetic concerns and concepts for cesarean hysterectomy.

PURPOSE OF REVIEW: Peripartum hemorrhage still remains a significant source of maternal morbidity and mortality worldwide. Abnormal placentation is one of the leading causes of peripartum hemorrhage. RECENT FINDINGS: The incidence of abnormal placentation is increasing secondary to the increased incidence of cesarean section. The main forms of abnormal placentation include placenta accreta, placenta previa and low-lying placenta. Historically placenta accreta was an incidental finding at the time of delivery and was associated with high maternal morbidity and mortality. The development of new imaging techniques such as magnetic resonance imaging and transvaginal color Doppler sonography has allowed antenatal diagnosis of this condition and elective preoperative planning of the obstetric and anesthetic management of these patients. Optimum management for most cases requires elective cesarean hysterectomy, performed ideally at about 34 weeks' gestation. SUMMARY: The present article is an update on the state-of-the art multidisciplinary management of parturients undergoing cesarean hysterectomy with special emphasis on anesthetic considerations. It summarizes the prevention, management and treatment of obstetric hemorrhages in parturients with abnormal placentation and highlights recent advances and developments. The obstetrician and the obstetric anesthesiologist must know, on the spot, how to deal with abnormal placentation-related peripartum bleeding. A multidisciplinary approach results in best outcomes.

Postoperative pain control in the parturient: new challenges in the new millennium.

In the new millennium, the horizons of modern anesthesia practice continue to expand beyond the provision of surgical anesthesia to encompass areas outside of the operating room, including preoperative evaluation, labor analgesia, postanesthesia care, critical care and acute and chronic pain management. Adequate postoperative analgesia following caesarean delivery hastens ambulation, decreases maternal morbidity, improves patient outcome, and facilitates care of the newborn. There is currently no "gold standard" for post-cesarean pain management. The number of options is large and the choice of the method of pain control is determined by drug availability, institutional protocols, individual preferences, available resources, and financial considerations. This article provides an overview of the currently available methods of post-cesarean analgesia.

A review of obstetric anesthesia in the new millennium: where we are and where is it heading?

PURPOSE OF REVIEW: The present article is an update on the state-of-the-art practice of obstetric anesthesia in the new millennium. It explores a number of important issues in this relatively new and still evolving subspecialty of anesthesiology. RECENT FINDINGS: Obstetric anesthesia is a subspecialty of anesthesiology dedicated to peripartum, perioperative pain and anesthetic management of women during pregnancy and the puerperium. In the new millennium an obstetric anesthesiologist has become an essential member of the peripartum care team, who closely works with the obstetrician, perinatologist, midwife, neonatologist, and labor and delivery nurse to ensure the highest quality care for the pregnant woman and her child. SUMMARY: Changes in maternal-fetal and neonatal medicine and obstetric anesthesia have been developing rapidly during the recent years and will continue to do so in the years to come. Obstetric anesthesia is art and science combined. An obstetric anesthesiologist is concerned simultaneously with the lives of at least two patients - the mother and her child. Exchange of information and communication skills in the ever changing environment of labor and delivery is essential for perfect outcome, which is always expected when providing passage for the mother and her baby from the antepartum to postpartum period.

Obstetric anesthesia: past present and future.

Obstetric anesthesia is science and art combined, and obstetric anesthesiologists must be concerned simultaneously with the lives of (at least two) intricately interwoven patients - the mother and her baby (ies). Obstetric anesthesia, by definition, is a subspecialty of anesthesia devoted to peripartum, perioperatvie, pain and anesthetic management of women during pregnancy and the puerperium. Perhaps no other subspecialty of anesthesiology provides more personal gratification than the practice of obstetric anesthesia. An obstetric anesthesiologist has become an essential member of the peripartum care team, who closely works with the obstetrician, perinatologist, midwife, neonatologist and labor and delivery nurse to ensure the highest quality care for the pregnant woman and her baby. Exchange on information and communication skills in ever changing environment of labor and delivery is essential for perfect outcome, which is always expected when providing safe passage for both the mother and her fetus from antepartum to postpartum period. Changes in maternal-fetal and neonatal medicine and obstetric anesthesia have continued to develop rapidly during the recent years. The purpose of this article is to explore a number of important issues in modern practice of obstetric anesthesia.

Implementing safe obstetric anesthesia in Eastern Europe.

The position of woman in any civilization is an index of the advancement of that civilization; the position of woman is gauged best by the care given her at the birth of her child. Obstetric anesthesia, by definition, is a subspecialty of anesthesia devoted to peripartum, perioperative, pain and anesthetic management of women during pregnancy and the puerperium. Today, obstetric anesthesia has become a recognized subspecialty of anesthesiology and an integral part of practice of most anesthesiologists. Perhaps, no other subspecialty of anesthesiology provides more personal gratification than the practice of obstetric anesthesia. This article reviews the challenges associated with implementing safe obstetric anesthesia practice in Eastern Europe.