The effects of maternal epidural anesthesia on neonatal behavior during the first month.

The effects of maternal epidural anesthesia with bupivacaine on the infant's performance on the Neonatal Behavioral Assessment Scale (NBAS) over the first month of life were examined. 20 non-medicated infants were matched for biomedical and demographic variables with 20 infants delivered with bupivacaine epidural anesthesia. The NBAS was administered on days 1, 3, 7 and 28. The epidural group showed poorer performance on the orientation and motor clusters during the first month of life. Epidural mothers reported spending less time with their infants while in the hospital; post hoc analyses showed that they had longer labor, more forceps deliveries and a greater amount of oxytocin. Controlling for the effects of these medical variables, a dose effect was found for the mean orientation and motor cluster scores. The results are discussed in terms of possible effects of the infant's early disorganization on the mother-infant interaction.

Influence of local anesthetic solution on postdural puncture headache.

A total of 2,511 patients who received spinal anesthesia for cesarean delivery were observed for the development of postdural puncture headache (PDPH); 804 patients received a mixture of tetracaine and procaine, 942 received bupivacaine-glucose, and 765 received lidocaine-glucose. They were observed for the development of PDPH for a minimum of 72 h. PDPH occurred in 9.54% of patients who received lidocaine-glucose during the first 36 h compared with 7.64% of patients who received bupivacaine-glucose and 5.85% of patients who received tetracaine-procaine. The differences between all groups was statistically significant. No differences were found in the percentage of patients who ultimately required epidural blood patch for relief of symptoms after 36 h.

pH adjustment of local anesthetic solutions with sodium bicarbonate: laboratory evaluation of alkalinization and precipitation.

pH adjustment of several commonly administered local anesthetic solutions was evaluated in the laboratory. The pH achieved after the addition of sodium bicarbonate and the onset of precipitation for alkalinized solutions were recorded. Solutions of 2-chloroprocaine and lidocaine readily alkalinized to near physiological pH without precipitation. Mepivacaine solutions exhibited a tendency for delayed precipitation (18-20-minute latency for 1.5% mepivacaine) above neutral pH. Bupivacaine and etidocaine solutions precipitated after the addition of small amounts of sodium bicarbonate and could not be alkalinized to physiologic pH. Two commercially available sodium bicarbonate preparations, 4% (wt/vol) and 8.4% (wt/vol), were compared and produced similar pH changes and precipitation behavior. The data obtained for pH and time to precipitation for local anesthetic solutions alkalinized with sodium bicarbonate may be useful for practical application in the clinical setting.

Perioperative analgesia with subarachnoid fentanyl-bupivacaine for cesarean delivery.

Addition of fentanyl to bupivacaine administered for spinal anesthesia for cesarean delivery was evaluated in 56 ASA physical status 1 term parturients. Preservative-free saline was added to 0, 2.5, 5, 6.25, 12.5, 25, 37.5, or 50 micrograms fentanyl to make a 1 ml total volume, which was injected intrathecally prior to bupivacaine in a double-blind, randomized fashion. Vital signs, sensory level, motor block, pain score, and side effects were recorded every 2 min for the first 12 min and then at 15, 30, 45, and 60 min and at 30-min intervals until the patient complained of pain. At delivery maternal vein, umbilical artery, and umbilical vein blood gases were obtained. Apgar scores at 1 and 5 min were recorded. Early Neonatal Neurobehavioral Scales (ENNS) were performed on days 1 and 2. Side effects and opioid requirements were recorded for the first 24 h. All of the patients in the control group reported a pain score greater than 0 during surgery and 67% required intraoperative opioids. None of the patients who received greater than or equal to 6.25 micrograms fentanyl required intraoperative opioids. Complete analgesia (time from injection to first report of pain) lasted 33.7 +/- 30.8 min (mean +/- SD) in the control group and increased to 130 +/- 30 min (P less than 0.05) with addition of 6.25 micrograms fentanyl. Duration of effective analgesia (time from injection to first parenteral opioid) was 71.8 +/- 43.2 min in the control group and increased (P less than 0.05) to 192 +/- 74.9 min with addition of 6.25 micrograms fentanyl.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidural butorphanol-bupivacaine for analgesia during labor and delivery.

A double-blind, randomized, dose-response study of a combination of 0.25% bupivacaine combined with 0, 1, 2, or 3 mg of butorphanol was studied in 40 laboring parturients. The optimal dose of butorphanol combined with 8.5 to 10 ml 0.25% bupivacaine was 2 mg; with 2 mg, the duration of analgesia was significantly greater and the time to onset of analgesia significantly shorter than when no butorphanol was added, and the amount of bupivacaine could be reduced 50%. Adverse fetal effects were not observed except that of a low amplitude sinusoidal fetal heart rate pattern with doses of 3 mg butorphanol. All neonatal observations were normal. It is concluded that epidural butorphanol can be a useful and safe adjunct to bupivacaine used for epidural analgesia during labor.

Fetal surgery and general anesthesia: a case report and review.

Fetal surgery, in utero, is now a viable option for some congenital conditions due to recent advances in ultrasound and microsurgical technology. Previous reports of anesthesia for such procedures have focused on spinal or epidural conduction techniques. General endotracheal anesthesia may have several advantages in this setting. In addition to maternal anesthesia, general anesthesia can provide fetal neuromuscular block (without direct fetal injection of blocking agents) and uterine relaxation. It may also blunt fetal response to surgical stimulation.

Delivery temperature of heated intravenous solutions during rapid infusion.

Warming of intravenous fluids may help to prevent shivering and hypothermia in the surgical patient. Increasing the fluid temperatures to as high as 60 degrees C has been suggested. An in vitro study was performed in which temperature changes following the rapid infusion of heated lactated Ringer's solution within a vein were measured. When 1 L of solution was warmed to 55 degrees C and then was infused over 4 min, local model vein temperatures rose from 37 degrees C to 44 degrees C. This effect of possible regional tissue heating may well occur in vivo. It is known that the rate of human blood cell hemolysis and membrane enzymatic function is affected by temperature. Further efforts need to be directed toward appreciating the effects of warmed intravenous fluids upon intact physiologic preparations and red blood cells.

Anesthetic-related maternal mortality, 1954 to 1985.

This is a population-based study of the safety of obstetrical anesthesia in the Commonwealth of Massachusetts between 1954 and 1985. We used data collected by the state Committee on Maternal Mortality, which was founded in 1941. There were a total of 37 maternal deaths during the study period due to anesthetic-related complications. During the same time period, there were 886 maternal deaths. Thus, anesthetic-related mortality comprised 4.2% of all deaths, and the mortality rate was 1.5 per 100,000 live births between 1955 and 1964, 1.5 per 100,000 live births between 1965 and 1974, and 0.4 per 100,000 live births between 1975 and 1984. In the first decade of this study, aspiration during administration of a mask anesthetic was the primary cause of death. During the second decade, cardiovascular collapse associated with regional anesthesia was the primary cause of death. During the last decade of this study, all deaths were associated with general endotracheal anesthesia. As a result of this study and having identified the changes in the standard of care in Massachusetts that led to the reduction in maternal mortality, we offer recommendations to further improve the safety of anesthesia for childbirth in this country.

Anesthesia for the obstetric patient with multiple sclerosis.

Data on all obstetric patients delivering at the Brigham and Women's Hospital during the years 1982 through 1987 were collected. The anesthetic techniques used, the type and amount of anesthetic agents administered, and the postpartum relapse rate of multiple sclerosis patients were compared. Women who received epidural anesthesia for vaginal delivery did not have a significantly higher incidence of relapse than those who received local infiltration. However, all of the women who experienced postpartum relapses had received concentrations of bupivacaine greater than 0.25%. This finding may suggest that a higher concentration of drug over a longer period of time may adversely influence the relapse rate.

Resuscitation of the newborn.

The simple mnemonic ABCDE summarizes the five key principles of neonatal resuscitation: 1. Airway 2. Breathing 3. Circulation 4. Drugs 5. Evaluation of concurrent and causative problems and maintenance of a neutral thermal Environment.

Anesthesia for the high-risk parturient.

High-risk pregnancies require specialized obstetric and anesthetic care. A basic understanding of how specific pathophysiology and pharmacologic therapy interact with anesthetic care is essential for both obstetrician and anesthesiologist. This paper selectively focuses on preeclampsia/eclampsia, diabetes mellitus, prematurity, multiple gestations, infectious disease, preexisting neurologic disease, and preexisting cardiac disease, reviewing anesthesia for labor and vaginal and cesarean delivery for each high-risk problem, as practiced at a Level III perinatal unit. Emphasis will be placed, when appropriate, on recent experience with monitoring and aggressive pharmacologic therapy of the critically ill parturient.