Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis.

Some, but not all studies have suggested intra-operative use of nitrous oxide is correlated with postoperative nausea and vomiting. We performed a meta-analysis of randomised controlled trials to compare the incidence of nausea and vomiting in adults following general anaesthesia with or without nitrous oxide. We retrieved 30 studies (incorporating 33 separate trials) that investigated a 'nitrous oxide group' (total 2297 patients) vs a 'no-nitrous oxide group' (2301 patients). Omitting nitrous oxide significantly reduced postoperative nausea and vomiting (pooled relative risk 0.80, 95% CI 0.71-0.90, p = 0.0003). However, the absolute incidence of nausea and vomiting was high in both the nitrous oxide and no-nitrous oxide groups (33% vs 27%, respectively). In subgroup analysis, the maximal risk reduction was obtained in female patients (pooled relative risk 0.76, 95% CI 0.60-0.96). When nitrous oxide was used in combination with propofol, the antiemetic effect of the latter appeared to compensate the emetogenic effect of nitrous oxide (pooled relative risk 0.94, 95% CI 0.77-1.15). We conclude that avoiding nitrous oxide does reduce the risk of postoperative nausea and vomiting, especially in women, but the overall impact is modest.

Predictive value of six risk scores for outcome after surgical repair of hip fracture in elderly patients.

BACKGROUND: Hip fracture surgery is associated with high post-operative mortality and poor functional results: the excess mortality is 20% in the first year; of those patients who survive, only 50% recover their previous ability to walk. The purpose of this study was to assess the predictive value of six functional status and/or surgical risk scoring systems with regard to serious complications after hip fracture surgery in the elderly. METHODS: We performed a prospective study of a consecutive series of 232 patients (aged 65 years or older) undergoing hip fracture surgery. We pre-operatively applied: The American Society of Anesthesiologists classification, the Barthel index, the Goldman index, the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system, the Charlson index and the Visual Analogue Scale for Risk (RISK-VAS) scale. These scales were evaluated with respect to three variables: incidence of serious complications, the ability to walk after a 3-month period and 90-day survival. The predictive value of the different scales was assessed by the calculated area under a receiver operating characteristic curve. RESULTS: The RISK-VAS scale, the POSSUM scoring system and the Charlson index reached a sufficient predictive value with regard to serious post-operative complications. The Barthel index and the RISK-VAS scale were those most useful for predicting ambulation at 3 months. None of the scales proved to be capable of predicting 90-day mortality. CONCLUSIONS: A simple index such as the RISK-VAS scale was the best predictor of serious post-operative complications. The functional level before the fracture, measured with the Barthel index, had a major influence on the ambulation recovery.

[Epidural obstetric analgesia, maternal fever and neonatal wellness parameters]. / Analgesia epidural obstétrica, fiebre materna y parámetros de bienestar neonatal.

OBJECTIVE: To study the relation between epidural analgesia and the development of maternal fever during labor and childbirth, and to determine the possible relation between that association and neonatal welfare and in the performance of tests to rule out sepsis in newborns. PATIENTS AND METHODS: Prospective study of all women who gave birth at Fundación Hospital Alcorcón over a period of 3 years. All the women were offered epidural analgesia based on infusion of 0.0625% bupivacaine and 2 microg x mL(-1). Data collected were age, nulliparity, epidural analgesia infusion, induction of labor, uterine stimulation with oxytocin, type of birth, fetal weight, duration of dilation and expulsion, Apgar score (at 1 and 5 minutes), umbilical artery pH, and maternal temperature. RESULTS: Data for 4364 women were analyzed. Fever developed during labor in 5.7%; 93.7% of the fevers occurred in women receiving epidural analgesia (P<0.05). Logistic regression analysis revealed that independent risk factors for the development of fever were epidural analgesia (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.05-3.04), nulliparity (OR, 2,929; 95% CI, 2.005-4.279), fetal weight (OR, 1.484; 95% CI, 1.102-2.001), and duration of labor (OR, 1.003; 95% CI, 1.003-1.004). No significant differences in Apgar score at 5 minutes or umbilical artery pH were found between the women with and without fever. Tests to rule out sepsis were ordered for 85.1% of the infants of mothers with fever after epidural analgesia. CONCLUSIONS: Epidural analgesia was associated with greater risk of developing fever in mothers giving birth, but that association had no repercussion on the neonatal wellness parameters studied.

Analgesia epidural obstétrica, fiebre materna y parámetros de bienestar neonatal / Epidural obstetric analgesia, maternal fever and neonatal wellness parameters

OBJETIVO: Estudiar la relación entre la analgesia epidural y el desarrollo de fiebre materna intraparto así como la posible repercusión de tal asociación en el bienestar neonatal y en la realización de pruebas para descartar sepsis en el recién nacido. PACIENTES Y MÉTODOS: Estudio prospectivo que incluyó a todas las mujeres que dieron a luz en la Fundación Hospital Alcorcón durante 3 años. Se ofertó la administración de analgesia epidural -basada en una perfusión de bupivacaína al 0,0625% más fentanilo a 2 μg mL-1- a todas las gestantes. Se recogieron: edad, nuliparidad, administración de analgesia epidural, inducción del parto, estimulación uterina con oxitocina, tipo de parto, peso fetal, duración de la dilatación y del expulsivo, puntuación Apgar (minutos 1 y 5), pH de la arteria umbilical y temperatura materna. RESULTADOS: Se analizaron los datos de 4.364 mujeres. El 5,7% desarrolló fiebre durante el parto. El 93,7% de los casos de fiebre intraparto ocurrieron dentro del grupo de mujeres con analgesia epidural (p < 0,05). El análisis de regresión logística reveló que la analgesia epidural (OR: 1,78, IC 95%: 1,04-3,04), la nuliparidad (OR: 2,929, IC 95%: 2,005-4,279), el peso fetal (OR: 1,484, IC 95%: 1,102- 2,001) y la duración del parto (OR: 1,003, IC 95%: 1,003- 1,004) fueron factores de riesgo independientes para desarrollo de fiebre. No se encontraron diferencias en la puntuación Apgar 5 min ni en el pH arterial umbilical entre los recién nacidos de mujeres con fiebre y sin ella. El 85,1% de los recién nacidos de madres con fiebre tras analgesia epidural fue sometido a pruebas para descartar sepsis. CONCLUSIONES: La analgesia epidural se asoció con un mayor riesgo de desarrollar fiebre materna; dicha asociación no tuvo repercusión sobre los parámetros de bienestar neonatal estudiados. OBJETIVO: Estudiar la relación entre la analgesia epidural y el desarrollo de fiebre materna intraparto así como la posible repercusión de tal asociación en el bienestar neonatal y en la realización de pruebas para descartar sepsis en el recién nacido. PACIENTES Y MÉTODOS: Estudio prospectivo que incluyó a todas las mujeres que dieron a luz en la Fundación Hospital Alcorcón durante 3 años. Se ofertó la administración de analgesia epidural -basada en una perfusión de bupivacaína al 0,0625% más fentanilo a 2 μg mL-1- a todas las gestantes. Se recogieron: edad, nuliparidad, administración de analgesia epidural, inducción del parto, estimulación uterina con oxitocina, tipo de parto, peso fetal, duración de la dilatación y del expulsivo, puntuación Apgar (minutos 1 y 5), pH de la arteria umbilical y temperatura materna. RESULTADOS: Se analizaron los datos de 4.364 mujeres. El 5,7% desarrolló fiebre durante el parto. El 93,7% de los casos de fiebre intraparto ocurrieron dentro del grupo de mujeres con analgesia epidural (p < 0,05). El análisis de regresión logística reveló que la analgesia epidural (OR: 1,78, IC 95%: 1,04-3,04), la nuliparidad (OR: 2,929, IC 95%: 2,005-4,279), el peso fetal (OR: 1,484, IC 95%: 1,102- 2,001) y la duración del parto (OR: 1,003, IC 95%: 1,003- 1,004) fueron factores de riesgo independientes para desarrollo de fiebre. No se encontraron diferencias en la puntuación Apgar 5 min ni en el pH arterial umbilical entre los recién nacidos de mujeres con fiebre y sin ella. El 85,1% de los recién nacidos de madres con fiebre tras analgesia epidural fue sometido a pruebas para descartar sepsis. CONCLUSIONES: La analgesia epidural se asoció con un mayor riesgo de desarrollar fiebre materna; dicha asociación no tuvo repercusión sobre los parámetros de bienestar neonatal estudiados

OBJECTIVE: To study the relation between epidural analgesia and the development of maternal fever during labor and childbirth, and to determine the possible relation between that association and neonatal welfare and in the performance of tests to rule out sepsis in newborns. PATIENTS AND METHODS: Prospective study of all women who gave birth at Fundación Hospital Alcorcón over a period of 3 years. All the women were offered epidural analgesia based on infusion of 0.0625% bupivacaine and 2 μg•mL-1. Data collected were age, nulli-parity, epidural analgesia infusion, induction of labor, uterine stimulation with oxytocin, type of birth, fetal weight, duration of dilation and expulsion, Apgar score (at 1 and 5 minutes), umbilical artery pH, and maternal temperature. RESULTS: Data for 4364 women were analyzed. Fever developed during labor in 5.7%; 93.7% of the fevers occurred in women receiving epidural analgesia (P<0.05). Logistic regression analysis revealed that independent risk factors for the development of fever were epidural analgesia (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.05-3.04), nulliparity (OR, 2,929; 95% CI, 2.005-4.279), fetal weight (OR, 1.484; 95% CI, 1.102-2.001), and duration of labor (OR, 1.003; 95% CI, 1.003-1.004). No significant differences in Apgar score at 5 minutes or umbilical artery pH were found between the women with and without fever. Tests to rule out sepsis were ordered for 85.1% of the infants of mothers with fever after epidural analgesia. CONCLUSIONS: Epidural analgesia was associated with greater risk of developing fever in mothers giving birth, but that association had no repercussion on the neonatal wellness parameters studied

[Obstetric epidural analgesia: relationship between obstetric variables and the course of labor]. / Analgesia epidural obstétrica: relación con diversas variables obstétricas y con la evolución del parto.

OBJECTIVES: To analyze the relationship between epidural analgesia and diverse obstetric and fetal variables as well as the impact of epidural analgesia on the rates of instrumental and cesarean delivery. PATIENTS AND METHODS: Observational study of women who gave birth at Fundación Hospital Alcorcón over a period of 3 years. All the women were offered obstetric epidural analgesia based on 0.0625% bupivacaine plus 2 microg/mL of fentanyl. The following data were recorded: age, nulliparity (yes/no) administration of epidural analgesia (yes/no), induction of labor (yes/no), stimulation of uterine activity with oxytocin (yes/no), type of delivery, fetal weight, duration of dilation, duration of expulsion, cause of cesarean. RESULTS: The records of 4364 women were gathered. The percentages of inductions, nulliparas, oxytocin stimulation, and fetal weight greater than 4 kg and less than 2.5 kg were higher among women taking epidural analgesia. The age of women who received epidurals was significantly lower. The durations of dilation and expulsion were longer among women receiving epidural analgesia, and epidural analgesia was associated with greater risk of instrumental and cesarean deliveries. The significant increase in administration of epidural blocks over the 3-year period of the study was not accompanied by an increased rate of instrumentally assisted deliveries or cesareans. CONCLUSIONS: It is difficult to evaluate the real influence of epidural analgesia on certain aspects of labor and its evolution. The strength of the association between epidural analgesia and greater risk of increased rates of instrumental and cesarean deliveries may be influenced by factors not considered in the present study.

Ropivacaína y bupivacaína para la analgesia epidural obstétrica / Ropivacaine and bupivacaine for obstetric epidural

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Anaesthesia-related diplopia after cataract surgery.

BACKGROUND: We studied the incidence and clinical characteristics of persistent diplopia related to anaesthesia for cataract surgery in a general hospital. METHODS: This was a retrospective review of anaesthesia for 3587 cataract surgeries. Of all the cases of diplopia referred to the ocular motility clinic after cataract surgery, those involving anaesthesia-related diplopia lasting longer than 1 month were studied. RESULTS: During the study period, 3450 cataract surgeries were performed by phacoemulsification and 137 by extracapsular extraction. Retrobulbar block was used in 2024 cases, peribulbar block in 98, topical anaesthesia in 1420 and general anaesthesia in 43. Twenty-six cases of persistent diplopia were found (0.72% incidence), nine of which (0.25%) were considered to be related to anaesthetic factors; five of the latter involved the left eye. Five were caused by paresis of the inferior rectus muscle and three by fibrosis. In one patient, the inferior oblique muscle was affected. Anaesthesia was by retrobulbar block in eight cases (0.39%) and by peribulbar block in one. No diplopia was found in patients who had topical or general anaesthesia. Treatment was with surgery in two patients and with prisms in six. One patient continues to be studied. CONCLUSIONS: Persistent diplopia can occur after cataract surgery using retrobulbar block predominantly through direct damage to the inferior rectus muscle. The overall incidence of anaesthesia-related diplopia in this series was 0.25%.

A comparison of 0.5% ropivacaine and 1% mepivacaine for sciatic nerve block in the popliteal fossa.

BACKGROUND: The purpose of this study was to compare anesthetic efficacy and postoperative analgesia of 0.5% ropivacaine and 1% mepivacaine for sciatic nerve block in the popliteal fossa (popliteal block). METHODS: A prospective, double-blind study was carried out in 58 adult patients scheduled for outpatient foot or ankle surgery. They were randomized to receive popliteal block with 40 ml of either 0.5% ropivacaine (group R) or 1% mepivacaine (group M). An atraumatic, Teflon-coated needle connected to a neurostimulator was used to make a single puncture using a posterior approach. The times to onset of sensory and motor block, and the need for intraoperative sedation were recorded. Before discharge, patients were asked to document the time to first analgesic use, time to return of full sensation in the foot, and their evaluation of the technique. RESULTS: Onset time (mean+/-standard deviation, 95% confidence interval) of both sensory block (6.5+/-5.1 min, 4.47-8.49, in group R and 6.2+/-3.7 min, 4.83-7.69, in group M) and motor block (6.6+/-4.4 min, 4.81-8.23, in group R and 7.9+/-4.1 min, 6.29-9.53, in group M) was similar in both groups. Postoperative analgesia lasted longer in group R (15.2+/-5.1 h, 13.25-17.21) than in group M (5.7+/-1.8 h, 5.01-6.41; P<0.001). Duration of sensory block was longer in group R (20.7+/-6.2 h, 18.51-23.01) than in group M (6.5+/-1.7 h, 5.86-7.16; P<0.001). Acceptance of the anesthetic procedure was similar in both groups. CONCLUSION: In this study we demonstrated that both 0.5% ropivacaine and 1% mepivacaine for popliteal block produced rapid, effective and safe anesthesia but postoperative analgesia was more long-lasting with ropivacaine.

A comparison of 0.0625% bupivacaine with fentanyl and 0.1% ropivacaine with fentanyl for continuous epidural labor analgesia.

UNLABELLED: We compared the analgesic efficacy and the degree of motor block achieved with epidural infusion of 0.0625% bupivacaine (Group B) versus 0.1% ropivacaine (Group R), both with 0.0002% fentanyl (2 microg/mL) in laboring patients. A prospective, double-blinded study was performed in 98 ASA physical status I-II parturients who were divided randomly into two groups to receive either bupivacaine or ropivacaine after catheter location had been tested with an initial bolus of lidocaine and fentanyl. The infusion rate was 15 mL/h in every case. When pain was perceived, 5-mL boluses of the assigned epidural analgesic were administered every 10 min until analgesia was achieved. We recorded pain intensity, level of sensory block, degree of motor block, hemodynamic variables, secondary effects, mode of delivery, neonatal outcome, and patient satisfaction. There were no statistically significant differences in any of the factors analyzed. Highly effective analgesia was achieved in both groups with a small incidence of motor block. These findings suggest that bupivacaine may be more potent than ropivacaine. IMPLICATIONS: We compared different concentrations of epidural bupivacaine and ropivacaine thought to be equipotent. Both solutions were equally efficient in providing highly effective epidural analgesia for labor with minimal motor block. These findings suggest that bupivacaine may be more potent than ropivacaine.

[Combined subarachnoid-epidural technique for obstetric analgesia]. / Técnica combinada subaracnoidea-epidural para la analgesia obstétrica.

Combined spinal-epidural blockade for labor pain has enjoyed increasing popularity in obstetric anesthesia. The usual procedure is to use a single space and a single needle for dural puncture, inserting a spinal needle through an epidural needle followed by insertion of a catheter. A small dose of one or several substances (usually a lipophilic opioid and a local anesthetic) is first injected in the intrathecal space to provide rapid, effective analgesia with minimal muscle blockade. The epidural catheter is used if labor lasts longer than the spinal block, if the spinal block is insufficient, or in case of cesarean section. Combined spinal-epidural blockade is a safe, valid alternative to conventional epidural analgesia and has become the main technique for providing obstetric analgesia in many hospitals. The most widely-recognized advantage of the technique is high maternal satisfaction with rapid and effective analgesia. Mobility of the lower extremities is preserved and the mother is often able to walk. Because opioids are injected into the intrathecal space and because the technique is more invasive than standard epidural analgesia, the potential risk to mother and fetus increases.

Técnica combinada subaracnoidea-epidural para la analgesia obstétrica / Combined spinal-epidural analgesia in obstetrics

El uso del bloqueo combinado subaracnoideo-epidural para el dolor de parto ha cobrado cada vez mayor interés en la anestesia obstétrica. El procedimiento más habitual se efectúa en un solo espacio y con una única aguja y consiste en la realización de una punción dural -pasando una aguja espinal a través de una epidural- seguida de la introducción de un catéter epidural. Primero se administran pequeñas dosis de una o varias sustancias por vía intratecal (habitualmente un opiáceo liposoluble y un anestésico local) con el objetivo de conseguir una analgesia rápida y eficaz con un bloqueo muscular mínimo. El catéter epidural se aprovecha si el parto dura más que el bloqueo subaracnoideo, si éste no es completamente eficaz, y en caso de cesárea.El bloqueo combinado subaracnoideo-epidural constituye una alternativa válida y segura a la epidural convencional, y en muchos centros se ha convertido en el método principal de analgesia obstétrica. La ventaja más aceptada de esta técnica es su alta satisfacción materna debido a su rapidez y eficacia analgésica y a que preserva la movilidad de las piernas, que en muchas ocasiones hace posible la deambulación de la parturienta. El uso de opiáceos intratecales y el hecho de ser una técnica más invasiva que la epidural estándar conlleva mayores riesgos potenciales para la madre y el feto (AU)

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[Pseudomembranous colitis complicated with toxic megacolon. Report of a case]. / Colitis seudomembranosa complicada con un megacolon tóxico. A propósito de un caso.

We present a patient who developed pseudomembranous colitis a few days after suffering serious multiple traumas and after receiving a variety of antibiotic treatments. The patient, whose condition was further complicated by toxic megacolon, underwent subtotal colectomy and ileostomy. Toxic megacolon is a rare complication of enterocolitis due to C. difficile and is associated with a high rate of mortality. We review the cases published to date, describe the pathogenesis of the condition, and discuss the diagnostic criteria for pseudomembranous colitis, emphasizing treatment and possible complications.

[ 2 cases of tension pneumopericardium after unilateral lung transplantation]. / Dos casos de neumopericardio a tensión tras trasplante pulmonar unilateral.

We present 2 patients who developed tension pneumopericardium after undergoing unilateral lung transplantation, describing their clinical evolution after surgery until the diagnosis of tension pneumopericardium. In both cases aspiration of air from the pericardium resulted in improved hemodynamic status. Tension pneumopericardium is rare in adults. Our patients were at high risk due to the difficulty of ventilating native and implanted lungs with different compliances. Moreover, the passage of air from the mediastinum to the pericardium is facilitated by the large opening made in order to dissect the pulmonary veins.

[Experience with the first 10 cases of percutaneous tracheostomy carried out at the recovery unit]. / Experiencia con los diez primeros casos de traqueostomía percutánea realizados en la unidad de reaninación.

The indications for percutaneous tracheostomy (PT) are the same as those for conventional tracheostomy. First described in 1969, PT has gradually become more widely used. We analyze the first 10 cases in which the procedure was performed in our postoperative intensive care unit. PT was performed in 10 patients admitted to the postoperative intensive care unit needing tracheostomy, following the procedure of Cook (Bjaeverskov, Denmark). Complications appearing during the procedure or later in the study period were recorded. All 10 PT procedures were successful. The mean time was 11.9 min (+/- 5.9). Minor complications developed in 5 patients. In 3 of these, the problems were technical (stylete slipping out, cannula hitting the endotracheal tube, and difficult insertion of a prepared cannula). The other 2 complications were small hemorrhages in the tracheostomy. No episodes of hypoxemia occurred during PT. The only late complication was a tracheostomy infection in a patient. In our experience PT is a useful alternative to conventional tracheostomy. The technique is easy to learn and performed quickly. Complications that develop do not affect the ultimate success of threaten patient stability.