Programmed intermittent epidural bolus as an ideal method for labor analgesia: a randomized controlled trial.

BACKGROUND: Although programmed intermittent epidural bolus (PIEB) is effective for labor analgesia, an appropriate flow rate has not been established. Therefore, we investigated the analgesic effect based on different epidural injection flow rates. METHODS: Nulliparous women scheduled for spontaneous labor were enrolled in this randomized trial. After injection of intrathecal 0.2% ropivacaine 3 mg with fentanyl 20 µg, participants were randomized to three study groups. Epidural analgesics, 10 ml during one hour, were administered with patient controlled epidural analgesia as follows (0.2% ropivacaine 60 ml, fentanyl 180 µg, and 0.9% saline 40 ml): continuous (n = 28, 10 ml/h for continuous infusion), PIEB (n = 29, 240 ml/h for bolus infusion of 10 ml), or manual (n = 28, 1200 ml/h for bolus injection of 10 ml). The primary outcome was hourly consumption of the epidural solution. The time interval between labor analgesia and the first breakthrough pain was investigated. RESULTS: The median (Q1, Q3) hourly consumption of epidural anesthetics was significantly different among the groups (continuous: 14.3 [8.7, 16.9] ml, PIEB: 9.4 [6.2, 9.8] ml, manual: 8.6 [7.6, 9.9] ml; P < 0.001). The time to breakthrough pain for the PIEB group was longer than that for the other groups (continuous: 78.5 [35.8, 185.0] min, PIEB: 200.0 [88.5, 441.5] min, manual: 60.5 [37.3, 162.0] min, P = 0.027). CONCLUSIONS: PIEB, with a low-flow rate, provided more adequate labor analgesia than a continuous epidural infusion or manual injection with a high-flow rate.

Second-generation laryngeal mask airway as an alternative to endotracheal tube in prolonged laparoscopic abdominal surgery: a comparative analysis of intraoperative gas exchanges.

Introduction: Laryngeal mask airway (LMA), which is used in difficult airway maintenance conditions during emergencies, is rarely used in prolonged surgery despite its advantages over endotracheal tube (ETT). In this study, we conducted a comparative analysis of intraoperative gas exchanges between second-generation LMA and ETT during prolonged laparoscopic abdominal surgery. Methods: Prolonged surgery was defined as a surgery lasting more than 2 h. In total, 394 patients who underwent laparoscopic liver resection via either second-generation LMA or ETT were retrospectively analysed. The following parameters were compared between the two groups of patients: end-tidal pressure of carbon dioxide (ETCO2), tidal volume (TV), respiratory rate (RR), peak inspiratory pressure (PIP), arterial partial pressure of carbon dioxide (PaCO2), pH and ratio of arterial partial pressure of oxygen to fractional inspired oxygen (PFR) during surgery. In addition, the incidence of postoperative pulmonary complications (PPCs), including pulmonary aspiration, was compared. Results: The values of ETCO2, TV, RR and PIP during pneumoperitoneum were comparable between the two groups. Although PaCO2 at 2 h after induction was higher in patients in the LMA group (40.5 vs. 38.5 mmHg, P < 0.001), the pH and PFR values of the two groups were comparable. The incidence of PPC was similar. Conclusion: During prolonged laparoscopic abdominal surgery, second-generation LMA facilitates adequate intraoperative gas exchange and may serve as an alternative to ETT.

Degree of intrapartum fever and associated factors: Three group analysis of no fever, borderline and overt fever.

AIM: Previous studies analyzing intrapartum fever by dichotomization of fever just above 38.0°C or not may lead to overlook clinical significance of borderline fever. We aimed to investigate the maternal baseline and intrapartum characteristics, neonatal outcomes, and inflammatory placental pathology in relation to the degree of intrapartum fever by three group analysis. METHODS: We performed a retrospective analysis of consecutive singleton deliveries between 370/7 to 410/7 weeks divided into three groups based on the peak body temperature during labor: No fever (< 37.5°C), borderline fever (≥ 37.5°C and < 38.0°C), and overt fever (≥ 38.0°C). Maternal and intrapartum characteristics, neonatal outcomes, and inflammatory placental pathology were compared by trend analysis, intergroup difference analysis, and multivariable analysis. RESULTS: The degree of intrapartum fever was significantly associated with younger maternal age, nulliparity, longer duration of rupture of membrane, and epidural analgesia (p < 0.001). And the incidence of neonatal proven sepsis and mortality were not significantly different among the groups. The degree of intrapartum fever was associated with the stage of acute chorioamnionitis and funisitis (p < 0.001). Multivariate analysis revealed that the association with epidural analgesia was stronger in borderline fever than overt fever (adjusted odds ratio [95% confidence interval], borderline fever = 18.487 [11.447-29.857]; overt fever = 11.068 [4.874-25.133]) after controlling for maternal age, parity, induction or augmentation, duration of ROM, birth weight, and meconium staining. CONCLUSION: Our data support that both epidural analgesia and inflammation of the placenta may contribute to the development of intrapartum fever at term.

Comparison of Pulmonary Gas Exchange During Kidney Transplantation: Second-Generation Laryngeal Mask Airway vs Endotracheal Tube.

INTRODUCTION: We evaluated whether second-generation laryngeal mask airway (LMA) could provide an adequate pulmonary gas exchange during prolonged abdominal surgery compared to endotracheal tube (ETT) using propensity score matching. METHODS: Of the 257 recipients who underwent living donor kidney transplantation (LDKT), the LMA group and ETT group were matched: 87 of 101 recipients who inserted second-generation LMA were matched with 87 of 156 recipients who inserted ETT. Arterial partial pressure of carbon dioxide (PaCO2) and ratio of arterial partial pressure of oxygen to fractional inspired oxygen (PFR) and intraoperative ventilator parameters were compared between the 2 groups. In addition, we compared incidences of postoperative pulmonary and nonpulmonary complications including hoarseness, vocal cord palsy, nausea, vomiting, arrhythmia, and delirium between the 2 groups. RESULTS: Median anesthesia time was 357 minutes. PaCO2 and PFR were comparable between the 2 groups and did not show group and time interaction. Ventilator parameters during surgery were comparable, and incidences of both postoperative pulmonary and nonpulmonary complications were also comparable between the 2 groups. CONCLUSION: Second-generation LMA could provide an adequate pulmonary gas exchange compared with ETT during LDKT. In terms of pulmonary gas exchange, second-generation LMA could be considered as a suitable alternative to ETT during prolonged abdominal surgery.

Reduced Hemidiaphragmatic Paresis With a "Corner Pocket" Technique for Supraclavicular Brachial Plexus Block: Single-Center, Observer-Blinded, Randomized Controlled Trial.

BACKGROUND AND OBJECTIVE: Hemidiaphragmatic paresis is common after supraclavicular brachial plexus block (SCBPB). In this randomized trial, we compared the incidence of hemidiaphragmatic paresis in patients who had local anesthetic injected primarily in the corner pocket (defined as the intersection of the first rib and subclavian artery) during SCBPB with that of patients who underwent injection primarily inside the neural cluster. METHODS: Thirty-six patients scheduled for right elbow, forearm, wrist, or hand surgery under SCBPB (using 12.5 mL of 0.75% ropivacaine and 12.5 mL of 2% lidocaine with 1:200,000 epinephrine) were randomly assigned to 1 of 2 groups. In group CP, local anesthetic was injected primarily in the corner pocket (20 mL) and secondarily inside the neural cluster (5 mL). In group NC, local anesthetic was deposited primarily inside the neural cluster (20 mL) and secondarily in the corner pocket (5 mL). The primary outcome was the incidence of hemidiaphragmatic paresis, as measured by M-mode ultrasonography 30 minutes after SCBPB. RESULTS: The incidence of hemidiaphragmatic paresis was significantly lower in group CP than in group NC (27.8% vs 66.7%, P = 0.019). The median decreases in forced expiratory volume at 1 second (7.5% [interquartile range, 3.3%-17.1%] vs 24.4% [interquartile range, 10.2%-31.2%]; P = 0.010) and forced vital capacity (6.4% [interquartile range, 3.3%-11.1%] vs 19.3% [interquartile range, 13.7%-33.2%]; P = 0.001) were also lower in group CP than in group NC. CONCLUSIONS: The incidence of hemidiaphragmatic paresis was effectively reduced when local anesthetic was injected primarily in the corner pocket during right-sided SCBPB. However, the 28% incidence of hemidiaphragmatic paresis associated with the corner pocket technique may still represent a prohibitive risk for patients with preexisting pulmonary compromise. CLINICAL TRIAL REGISTRATION: This study was registered at Clinical Trial Registry of Korea, identifier KCT0001769.

Emergency cesarean section in an epidemic of the middle east respiratory syndrome: a case report.

Only a few reports have been published on women with an infectious respiratory viral pathogen, such as Middle East Respiratory Syndrome (MERS) Coronavirus delivering a baby. A laboratory confirmed case of MERS was reported during a MERS outbreak in the Republic of Korea in a woman at gestational week 35 + 4. She recovered, and delivered a healthy baby by emergency cesarean section (C-sec). We present the clinical course and the emergency C-sec in a pregnant woman with MERS.

The comparison of clinically relevant doses of intrathecal ropivacaine and levobupivacaine with fentanyl for labor analgesia.

BACKGROUND: Intrathecal labor analgesia using new local anesthetics such as ropivacaine or levobupivacaine becomes more popular by virtues of their safety and decreased motor weakness. However, the analgesic efficacy of the clinically effective intrathecal doses of these new local anesthetics combined with fentanyl has yet to be determined. METHODS: Sixty parturients who requested neuraxial analgesia in early active labor were randomly assigned to either ropivacaine (group R, n = 30) or levobupivacaine (group L, n = 30) group. Group R received 3 mg of intrathecal ropivacaine and the group L received 3 mg of intrathecal levobupivacaine mixed with 20 µg of fentanyl as part of a combined spinal-epidural (CSE) technique. The associated block parameters, such as pain scores, duration of analgesia, the highest levels of the sensory block and motor block scores 30 mins after the injection were compared between two groups. RESULTS: Intrathecal ropivacaine offered shorter analgesia (87 ± 41 min vs. 122 ± 56 min, P < 0.05) with lower sensory height (T8.5 vs. T6, P < 0.05) and led to lower incidence of complete analgesia (73 vs. 97%, P < 0.05) compared with intrathecal levobupivacaine. Although motor weakness was comparable in both groups, significantly weak perineal squeezing was noticed in Group L (7 of 30 parturients vs. 16 of 30, P < 0.05). CONCLUSIONS: Clinically relevant doses of intrathecal levobupivacaine in combination with fentanyl as part of a CSE technique provides more effective analgesia than equivalent doses of intrathecal ropivacaine in early labor, but is accompanied by slight motor weakness.

Magnesium added to bupivacaine prolongs the duration of analgesia after interscalene nerve block.

PURPOSE: Local anesthetic adjuvants have been studied previously in an attempt to prolong the duration of analgesia after peripheral nerve blockade. Magnesium has been shown to have an antinociceptive effect in animal and human pain models. We evaluated the effects of adding magnesium sulphate to long-acting local anesthetics for interscalene nerve block to prolong the duration of analgesia and improve the analgesic quality. METHODS: We enrolled 66 patients undergoing arthroscopic rotator cuff repair. The interscalene nerve block was performed with 0.5% bupivacaine 20 mL with epinephrine (1:200,000) plus either 10% magnesium sulphate 2 mL (Magnesium Group) or normal saline 2 mL (Saline Group). The following data were recorded for 24 hr after surgery: onset times and durations of sensory and motor blocks, analgesic duration, the pain numeric rating scale (NRS), postoperative fentanyl consumption, and complications. RESULTS: The duration of analgesia was longer in the Magnesium Group than in the Saline Group [mean and (standard deviation) 664 (188) min vs 553 (155) min, respectively; P = 0.017]. Patients in the Magnesium Group had significantly reduced pain NRS scores at 12 hr (P = 0.012), but the cumulative fentanyl consumption was similar in both groups. The onset times and durations of sensory and motor blocks were not significantly different between the two groups. CONCLUSION: The addition of magnesium sulphate to a bupivacaine-epinephrine mixture for interscalene nerve block prolongs the duration of analgesia and reduces postoperative pain.

Epidural anesthesia for cesarean section in a patient with Marfan syndrome and dural ectasia -A case report-.

Pregnancy is considered a period of high risk for cardiovascular complications in patients with Marfan syndrome. Therefore the choice of anesthetic technique for delivery should be focused on minimizing hemodynamic fluctuations, and preferably provide adequate post-operative pain control. For this purpose, neuraxial blocks, such as spinal or epidural anesthesia, may be deemed a safe option. However, dural ectasia is present in 63-92% of patients with Marfan syndrome, and the increased amount of cerebrospinal fluid volume is thought to be one of main reasons for spinal anesthesia failure. We report herein the peri-operative management of a patient with Marfan syndrome and dural ectasia for cesarean section using epidural anesthesia.

Effect of combined single-injection femoral nerve block and patient-controlled epidural analgesia in patients undergoing total knee replacement.

PURPOSE: Total knee replacement is one of the most painful orthopedic procedures, and effective pain relief is essential for early mobility and discharge from hospital. The aim of this study was to evaluate whether addition of single-injection femoral nerve block to epidural analgesia would provide better postoperative pain control, compared to epidural analgesia alone, after total knee replacement. MATERIALS AND METHODS: Thirty-eight patients received a single-injection femoral nerve block with 0.25% levobupivacaine (30 mL) combined with epidural analgesia (femoral nerve block group) and 40 patients received epidural analgesia alone (control group). Pain intensity and volume of patient-controlled epidural analgesia medication and rescue analgesic requirements were measured in the first 48 hours after surgery at three time periods; 0-6 hours, 6-24 hours, and 24-48 hours. Also, side effects such as nausea, vomiting, and pruritus were evaluated. RESULTS: Median visual analog scale at rest and movement was significantly lower until 48 hours in the femoral nerve block group. Patient-controlled epidural analgesia volume was significantly lower throughout the study period, however, rescue analgesia requirements were significantly lower only up to 6 hours in the femoral nerve block group. The incidences of nausea and vomiting and rescue antiemetic requirement were significantly lower in the femoral nerve block group up to 6 hours. CONCLUSION: The combination of femoral nerve block with epidural analgesia is an effective pain management regimen in patients undergoing unilateral total knee replacement.

Hemostatic and electrolyte effects of hydroxyethyl starches in patients undergoing posterior lumbar interbody fusion using pedicle screws and cages.

STUDY DESIGN: Prospective, randomized, double blind, clinical study. OBJECTIVE: To compare the hemostatic and electrolyte effects of 2 commonly administered hydroxyethyl starches (HES) in patients undergoing posterior lumbar interbody fusion (PLIF). SUMMARY OF BACKGROUND DATA: HES are commonly administered colloid solutions to restore and maintain intravascular volume before transfusion is initiated. However, infusion of HES itself can impair coagulation. HES-induced coagulopathy could be a serious problem in PLIF which involves continuous bone bleeding and oozing. Voluven (Fresenius Kabi, Germany), previously regarded as the least coagulopathic due to its low molecular weight (MW) and degree of substitution (DS), is a saline-based HES. Hextend (Biotime, United States) is a new type of HES with physiologic pH and balanced electrolytes, including calcium, which is beneficial to coagulation. Studies comparing the coagulopathy of Hextend and Voluven are rare. Therefore, coagulation, pH/electrolyte changes, and blood loss using Hextend and Voluven in patients undergoing PLIF were compared. METHODS.: Fifty-four patients scheduled for PLIF involving 3 vertebrae or less were randomly assigned to the Voluven or the Hextend group. Of each solution 15 mL/kg was administered during surgery. Blood loss, coagulation, and electrolyte profiles were checked before infusion and 5 minutes, 3 hours, and 24 hours after the end of infusion. RESULTS: The Hextend group showed slightly better electrolyte balance, however, more coagulation impairment and postoperative transfusion (37% vs. 11%) compared with the Voluven group. The effect of Hextend on coagulation lasted until 24 hours after infusion. CONCLUSION: If coagulopathy is a concern during PLIF, then, a HES with low MW/DS in a saline-based medium (Voluven) may be a better alternative than a HES with high MW/DS in a balanced salt medium (Hextend).

Combined spinal-epidural anesthesia for caesarian section in a patients with multiple sclerosis: A case report.

The use of neuroaxial blocks in patients with multiple sclerosis has been controversial, because the effect of local anesthetic drugs on the course of the disease is unclear. We report an obstetric patient with multiple sclerosis whose caesarian section was performed successfully under combined spinal-epidural anesthesia and postoperative pain control was managed using patient-controlled epidural analgesia. There were no exacerbation of neurologic symptoms and no relapse of disease at two month follow-up. We suggest that the choice of anesthetic technique for patients with multiple sclerosis should be determined after evaluation of the course of the disease and informed consent. The obstetric patients with multiple sclerosis should not be denied the neuroaxial block for labor and caesarian section.

Combination of antiemetics for the prevention of postoperative nausea and vomiting in high-risk patients.

It was previously reported that the Korean predictive model could be used to identify patients at high risk of postoperative nausea and vomiting (PONV). This study investigated whether PONV in the high-risk and very high-risk patients identified by the Korean predictive model could be prevented by multiple prophylactic antiemetics. A total of 2,456 patients were selected from our previous PONV study and assigned to the control group, and 374 new patients were recruited consecutively to the treatment group. Patients in each group were subdivided into two risk groups according to the Korean predictive model: high-risk group and very high-risk group. Patients in the treatment group received an antiemetic combination of dexamethasone 5 mg (minutes after induction) and ondansetron 4 mg (30 min before the end of surgery). The incidences of PONV were examined at two hours after the surgery in the postanesthetic care unit and, additionally, at 24 hr after the surgery in the ward, and were analyzed for any differences between the control and treatment groups. The overall incidence of PONV decreased significantly from 52.1% to 23.0% (p< or =0.001) after antiemetic prophylaxis. Specifically, the incidence decreased from 47.3% to 19.4% (p< or =0.001) in the high-risk group and from 61.3% to 28.3% (p< or =0.001) in the very high-risk group. Both groups showed a similar degree of relative risk reductions: 59.0% vs. 53.8% in the high-risk and very high-risk groups, respectively. The results of our study showed that the antiemetic prophylaxis with the combination of dexamethasone and ondansetron was effective in reducing the occurrence of PONV in both high-risk and very high-risk patients.

Relationship between the bevel of the Tuohy needle and catheter direction in thoracic epidural anesthesia.

BACKGROUND AND OBJECTIVES: Directing an epidural catheter cephalad or caudad is usually attempted by orienting the beveled edge of the epidural needle. However, there have been few studies about the relationship between the direction of the bevel of epidural needle and the resulting position of the catheter. We studied this relationship in thoracic epidural catheter placement. Catheter position was confirmed by using picture archiving communication systems (PACS). PACS is a workstation that stores radiologic images, which can be manipulated to visualize the catheters. METHODS: One hundred six patients receiving thoracic epidural anesthesia were enrolled. The cephalad and caudad groups (each with 53 patients) received epidural anesthesia at the T6-7 interspace with either a cephalad- or caudal-directed Tuohy needle. The final position of all of the catheters was confirmed by PACS. RESULTS: In the cephalad group, 63.5% of the catheters were confirmed to travel in a cephalad direction. In the caudad group, 22.0% of the catheters advanced in a caudad direction. Curling of the catheters occurred in 17.6%. PACS showed the catheter positions with satisfactory quality. CONCLUSIONS: The correlation between bevel direction and location of the thoracic epidural catheter was relatively low. Practices such as threading an epidural catheter by manipulation of the Tuohy needle for the control of pain at a distant site may not yield good results.

A korean predictive model for postoperative nausea and vomiting.

Postoperative nausea and vomiting (PONV) is one of the most common and distressing complications after surgery. An identification of risk factors associated with PONV would make it easier to select specific patients for effective antiemetic therapy. We designed a case-controlled study to identify the risk factors for PONV in 5,272 surgical patients. At postoperative 2 and 24 hr, patients were visited and interviewed on the presence and severity of PONV. Thirty nine percent of patients experienced one or more episodes of nausea or vomiting. Five risk factors were highly predictive of PONV: 1) female, 2) history of previous PONV or motion sickness, 3) duration of anesthesia more than 1 hour, 4) non-smoking status, and 5) use of opioid in the form of patient controlled analgesia (PCA), in the order of relevance. The formula to calculate the probability of PONV using the multiple regression analysis was as follows: P (probability of PONV)=1/1+e(-Z), Z=-1.885+0.894 (gender)+0.661 (history)+0.584 (duration of anesthesia)+0.196 (smoking status)+0.186 (use of PCA-based opioid) where gender: female=1, male=0; history of previous PONV or motion sickness: yes=1, no=0; duration of anesthesia:more than 1 hr=1, less than or 1 hr=0; smoking status: no=1, yes=0; use of PCA-based opioid: yes=1, no=0.

The effect of intrathecal gabapentin on mechanical and thermal hyperalgesia in neuropathic rats induced by spinal nerve ligation.

Gabapentin decreases the level of glutamate and elevates that of alpha-amino-butyric acid in the central nervous system. Gabapentin was shown to have antinociceptive effects in several facilitated pain models. Intrathecal gabapentin was also known to be effective in reducing mechanical allodynia in animals with neuropathic pain. In this study, we investigated to see whether intrathecal gabapentin produces antihyperalgesic effects on thermal and mechanical hyperalgesia in neuropathic rats and whether its effects are associated with motor impairment. To induce neuropathic pain in Sprague-Dawley rats, left L5 and L6 spinal nerves were ligated. After a week, lumbar catheterization into subarachnoid space was performed. Then, paw withdrawal times to thermal stimuli and vocalization thresholds to paw pressure were determined before and up to 2 hr after intrathecal injection of gabapentin. Also, motor functions including performance times on rota-rod were determined. Intrathecal gabapentin attenuated significantly thermal and mechanical hyperalgesia in neuropathic rats, but did not block thermal and mechanical nociception in sham-operated rats. Intrathecal gabapentin of antihyperalgesic doses inhibited motor coordination performance without evident ambulatory dysfunction. This study demonstrates that intrathecal gabapentin is effective against thermal and mechanical hyperalgesia, in spite of moderate impairment of motor coordination.