Anaesthetic management of labour and delivery in the parturient with mitochondrial myopathy.

PURPOSE: We describe the anaesthetic management for Caesarean section in a parturient with a defect in complex III of the respiratory chain who had increased lactate concentrations at rest and with exercise. CLINICAL FEATURES: We administered effective epidural anaesthesia with lidocaine for Caesarean delivery. The serum lactate concentration was less than the preoperative value both during and after surgery. Shivering during the perioperative period was avoided by administering warm i.v. fluids, warm local anaesthetic solution and epidural meperidine. Pain relief after surgery was provided with i.v. PCA morphine augmented by local infiltration with bupivacaine to fascia and skin edges and epidural injection with meperidine. CONCLUSION: Mitochondrial myopathies are an uncommon group of disorders in which mitochondrial dysfunction leads to clinical disease of muscle and sometimes of other organs with high energy requirements. The management of labour and delivery in women with mitochondrial myopathies should be individualized according to severity of disease and formulated by consultation between attending physicians and the anaesthetist. Epidural analgesia reduces stress and work associated with labour and reduces oxygen demand during labour. However, parturients with defects of the respiratory chain with documented increased lactate concentrations at rest and with exercise are best managed with elective Caesarean delivery with regional anaesthesia to prevent life-threatening lactic acidosis during labour. The association between malignant hyperthermia and these disorders has not been proved, but it appears prudent to consider these women as MH susceptible until definitive data regarding this possible relationship are available.

The efficacy of incentive spirometers in post-operative protocols for low-risk patients.

Incentive spirometry offered no statistically significant advantages to pulmonary function when compared to unstructured or structured deep breathing and coughing exercise programs, for patients at low risk of developing pulmonary complications. The additional cost of incentive spirometer equipment does not seem warranted in these patients. Furthermore, patients with or without an incentive spirometer were willing to comply with a structured breathing exercise program with the same frequency of practice sessions. Patients in this diagnostic category did not require a technical device to reward and motivate them for performing maximal inspiratory manoeuvres.

Comparison of morning versus evening dosing with a new once-daily oral theophylline formulation.

A double-blind, cross-over comparison of morning (8 A.M.) versus evening (10 P.M.) dosing regimens with a new once-daily oral theophylline (Uniphyl, Purdue Frederick) was performed. The comparison was based upon steady-state theophylline pharmacokinetics, spirometric measurements over 24 hours, the patients' quantitative reporting of asthmatic symptoms, and medication side effects. No statistically significant differences were observed in any theophylline parameter between the dosing regimens. Evening dosing, but not morning dosing, resulted in a significant attenuation of the early morning dip in pulmonary function. The morning severity of wheezing, chest tightness, and shortness of breath was significantly reduced after evening dosing. Overall no difference in the incidence of symptoms was noted. No significant differences in side effects were noted. Evening dosing with Uniphyl produced a significant improvement in morning pulmonary function, and this benefit was subjectively noted by the patients. No decline in this benefit was noted later in the day. Evening dosing with Uniphyl clearly is superior to morning dosing.