Management of pregnancy in a patient with severe haemophilia A.

Haemophilia A is a bleeding disorder that has a spectrum of manifestations ranging from persistent bleeding after minor trauma to spontaneous haemorrhage. As an X-linked disease, it has a rare occurrence in females. We report a case of a pregnant patient with severe haemophilia A, who received epidural analgesia during labour. The prepartum, intrapartum and postpartum care of a patient with such a bleeding diathesis is discussed.

Analgesia, pruritus, and ventilation exhibit a dose-response relationship in parturients receiving intrathecal fentanyl during labor.

UNLABELLED: Several studies have characterized the 50% and 95% effective doses (ED50 and ED95, respectively) of intrathecal sufentanil for labor analgesia. Few have investigated these same criteria for the less expensive alternative, fentanyl. In addition, the ventilatory effects of intrathecal fentanyl at clinically relevant doses are unclear. We performed this study to establish the dose-response relationship of intrathecal fentanyl for both analgesia and ventilatory depression. Ninety parturients in active early labor (< or = 5 cm dilation) received intrathecal fentanyl 5, 7.5, 10, 15, 20, or 25 micrograms in a double-blinded, randomized fashion (n = 15 patients in each group). Parturients were monitored for degree of pain (measured using a 100-mm visual analog pain scale), blood pressure, arterial oxygen saturation (SaO2), respiratory rate, ETCO2, and fetal heart rate 0, 1, 5, 10, 15, 20, 25, and 30 min after the administration of intrathecal fentanyl. An absolute visual analog pain scale score < or = 25 mm was defined a priori as analgesic success. The percentage of parturients who achieved analgesic success was used to construct quantal dose-response curves, from which the ED50 and ED95 values were derived for the total population (mixed parity) and the nulliparous and multiparous subpopulations separately. Overall ED50 and ED95 values (95% CI) were 5.5 (3.4-7.2) and 17.4 (13.8-27.1) micrograms, respectively. Nulliparous values were lower (5.3 and 15.9 micrograms, respectively) than multiparous values (6.9 and 26.0 micrograms, respectively) but were within the 95% CIs of the total population. Pruritus incidence in parturients with analgesic success displayed a dose-response relationship identical to that seen for analgesia. ETCO2 displayed a dose-related increase, particularly at doses > or = 15 micrograms, without concomitant changes in respiratory rate or SaO2, which suggests a decrease in tidal volume. Even in the absence of overt signs or symptoms of somnolence, intrathecal fentanyl at doses within the effective analgesic range induced a change in ventilation that may last longer than the 30-min period we studied. IMPLICATIONS: Intrathecal fentanyl induces rapid and satisfying dose-dependent analgesia in early labor; however, it also produces dose-related decreases in ventilation in the absence of overt somnolence.

Determination of the analgesic dose-response relationship for epidural fentanyl and sufentanil with bupivacaine 0.125% in laboring patients.

STUDY OBJECTIVE: To establish the analgesic effective doses as defined as a visual analog pain scale (VAS) of at least 10 for 95% of parturients (ED95) receiving either epidural fentanyl or sufentanil with bupivacaine 0.125% for labor analgesia. DESIGN: Double-blind, randomized controlled study. SETTING: Two tertiary-care teaching hospitals. PATIENTS: 100 female patients, at full-term pregnancy, in active early labor (< 5 cm cervical dilation) and requesting obstetric anesthesia services for labor analgesia. INTERVENTIONS: Patients were randomized and equally distributed to receive one of ten epidural dosing regimens of bupivacaine 0.125% alone or with either fentanyl 25, 50, 75, or 100 micrograms or sufentanil 5, 10, 15, 20, or 25 micrograms in a 10-ml bolus after a 3-ml test dose of bupivacaine 0.25%. MEASUREMENTS AND MAIN RESULTS: VAS scores were obtained from each parturient using a 10-cm plastic VAS slide rule at times 0, 1, 5, 10, 15, 20, 25, and 30 minutes, and then again when the patient requested additional analgesia. Analgesic duration and demographic and obstetric data also were obtained. Using a log-probit dose-response analysis, analgesic success as defined as a VAS of at least 10 with each opioid dose was plotted and an ED95 value of 8 micrograms and 50 micrograms was established for sufentanil and fentanyl, respectively, in bupivacaine 0.125%. No statistical difference was detected for analgesic duration or incidence of side effects between analgesic groups. CONCLUSIONS: Epidural analgesia with fentanyl and sufentanil in bupivacaine 0.125% behaves in a dose-response fashion allowing for the determination of equipotent dose of each.

Caesarean section in a diabetic patient with a recent myocardial infarction.

This is a report of a 38-yr-old parturient with multiple medical problems including diabetes mellitus, bronchial asthma, chronic myelogenous leukaemia, pre-eclampsia and a recent myocardial infarction. After medical management in the coronary care unit, it was decided to proceed with a Caesarean section. The choice of anaesthetic was made by the patient and had to be modified in accordance with her medical condition. Cardiovascular monitoring included PA catheterisation and transoesophageal echocardiography. A general anaesthetic was performed using fentanyl, thiopentone and succinylcholine. The outcome was satisfactory for both parturient and baby.

The effect of ondansetron on atracurium-induced neuromuscular blockade.

STUDY OBJECTIVE: To determine whether treatment with ondansetron, a new antiemetic drug, affects nondepolarizing neuromuscular blockade. DESIGN: Randomized, double-blind, prospective study. SETTING: Operating room at a university medical center. PATIENTS: 30 ASA physical status I and II patients scheduled for elective surgery. INTERVENTIONS: After the induction of anesthesia with midazolam 2 to 4 mg/kg, sodium thiopental 6 to 8 mg/kg, and fentanyl 4 to 8 micrograms/kg, the ulnar nerve was stimulated at the wrist through subcutaneous needle electrodes at a frequency of 0.15 Hz. The response to stimulation was measured and recorded with a force-displacement transducer applied to the thumb. Patients were randomized to one of three treatment groups. A steady baseline to ulnar nerve stimulation with nitrous oxide-oxygen-opioid-thiopental anesthesia was established. The first study group (Group 1) received a placebo, the second group (Group 2) received 8 mg of ondansetron, and the third group (Group 3) received 16 mg of ondansetron as an intravenous infusion over 5 minutes. Patients were then given incremental doses of atracurium 0.05 mg/kg at 3-minute intervals to establish approximately 95% twitch inhibition so as to construct a dose-response curve. An atracurium infusion was then begun to maintain a constant degree of neuromuscular blockade. At the end of surgery, patients were allowed to recover spontaneously, or pharmacologic antagonism of residual neuromuscular blockade was achieved with neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg. Mechanomyographic response to train-of-four stimuli (2 Hz for 2 seconds) every 20 seconds was monitored during the atracurium infusion and recovery from neuromuscular blockade. MEASUREMENTS AND MAIN RESULTS: Log dose-response curves were determined for the study groups and compared using analysis of variance (ANOVA). The 50%, 75%, and 95% effective doses (ED50, ED75, and ED95) were calculated from the equation describing the log dose-response. Maintenance infusion rates were determined, and the neostigmine-accelerated recovery index of 25% to 75% was measured for each group. The results were compared using ANOVA. There were no significant differences among the treatment groups with respect to maintenance infusion rate (7.8 +/- 1.8 micrograms/kg/min for Group 1, 7.7 +/- 2.5 micrograms/kg/min for Group 2, and 7.3 +/- 2.3 micrograms/kg/min for Group 3) or neostigmine-accelerated recovery interval of 25% to 75% (4.5 +/- 2.3 minutes, 4.4 +/- 3.1 minutes, 6.6 +/- 3.9 minutes in Groups 1, 2, and 3, respectively). The log dose-response data for Groups 1, 2, and 3 did not differ significantly (p = 0.068), and the calculated ED95 in each treatment group demonstrated no dose-related change (0.254 +/- 0.022, 0.279 +/- 0.033, and 0.240 +/- 0.022 for Groups 1, 2, and 3, respectively). CONCLUSIONS: Ondansetron is an antiemetic drug that can be used in the perioperative period without concern for potentiation of nondepolarizing neuromuscular blockade, change in atracurium maintenance dose, or change in rate of neostigmine-induced recovery from neuromuscular blockade with atracurium.

Venous emboli occurring caesarean section: the effect of patient position.

The effect of position, horizontal versus 5 degrees reverse Trendelenburg's, on the incidence of venous emboli during Caesarean section was evaluated in 207 patients. Venous emboli were diagnosed using precordial ultrasonic Doppler monitoring. In the horizontal position, 44% (60 of 134) parturients had venous emboli compared with 1% (1 of 73) parturients in the 5 degrees reverse Trendelenburg's position (P less than 0.0001). Epidural anaesthesia was performed in 171 patients, and 36 patients had general anaesthesia. In the epidural group, pulse oximetric haemoglobin oxygen desaturation and complaints of chest pain and/or dyspnoea were associated with the venous emboli. Venous emboli, probably air, occur frequently during Caesarean section with the patient in the horizontal position. This occurrence was minimized by placing the patient in the 5 degrees reverse Trendelenburg's position.

Are Doppler-detected venous emboli during cesarean section air emboli?

The incidence of venous emboli during cesarean section was studied using simultaneous precordial ultrasonic Doppler monitoring and two-dimensional echocardiography. Forty-nine patients receiving either general or continuous epidural anesthesia in the horizontal position were monitored with both Doppler monitoring and echocardiography. There was excellent correlation between the embolic events detected by Doppler monitoring and by echocardiography (kappa value = 1). The incidence of venous emboli was 29% (14/49). The venous emboli detected by Doppler monitoring were indeed air emboli, not amniotic fluid or thromboemboli, as illustrated by their echocardiographic appearance.

Precordial Doppler diagnosis of haemodynamically compromising air embolism during caesarean section.

This is a report of a 39-year-old parturient who had a haemodynamically compromising venous air embolism during a repeat Caesarean section under lumbar epidural anaesthesia. The embolism occurred immediately after surgical incision during surgery in the superficial subcutaneous tissues. The diagnosis was made using intraoperative precordial ultrasonic Doppler monitoring which allowed early and successful treatment.

Factors influencing utilization of the curative health services among children aged 6-60 months in Bahrain (Part II).

Two hundred twenty one out of 2587 children aged 6-60 months were selected at random from 8 villages in Western region of Bahrain. The data were collected by interviewing the mothers and checking out the health records. The study revealed that family size, mother's education, socioeconomic status and mother's attitude toward the curative services were significant factors for the use of the curative care. However, no significant relationships were found between the utilization of the curative care and age and sex of child, family structure and the situational factors.

Factors influencing utilization of the preventive health services among children aged 6-60 months in Bahrain. Part I.

Two-hundred fifty-eight out of 2587 children aged 6-60 months were randomly selected from eight villages in western region of Bahrain. The data were collected by visiting and interviewing the mothers, and examining the birth certificates for immunizations. Age of the child, family structure, sickness of the child and mother's attitude toward the provided preventive services were significant determinants for the use of preventive care. However, no significant relationships were found between utilization of the preventive care and child sex, family size, mother's education, socioeconomic status and situational factors.