Maternal and neonatal outcome after cesarean section: the impact of anesthesia.

BACKGROUND: Among the anesthetic technologies used, regional anesthesia is becoming the most common in cesarean section (CS) deliveries. Aim. This retrospective survey examined the variables taken into account when selecting the anesthetic technique to be used, and how this choice affects the outcome for the mother and the newborn. METHODS: One thousand eight hundred and seventy elective and emergency CS were evaluated for anesthetic technique used, indications, and maternal and neonatal outcome. RESULTS: Of the 611 elective CS (32.6%), 206 (33.8%) were performed under general anesthesia and 405 (66.2%) under regional anesthesia. Of the 1259 emergency CS performed (67.4%), 525 (41.9%) were under general anesthesia and 734 (58.1%) under regional anesthesia. Conditions associated with a newborn 1-minute Apgar score of <7 were general anesthesia and multiple pregnancy (p<0.01); a 5-minute Apgar score of <7 was only associated with multiple pregnancy. The most important factor for very low Apgar scores was the presence of fetal malformations. Whatever the chosen technique, neither maternal deaths directly or indirectly due to the anesthesia nor major maternal and perinatal complications were found. CONCLUSIONS: This survey confirms the preference for regional anesthesia during elective cesarean sections and for general anesthesia in emergency situations. Moreover, newborn outcome was found not to be influenced either by the technique used or by the character of the procedure.

Sevoflurane analgesia in obstetrics: a pilot study.

Continuous and intermittent administration of inhalational anesthetics has been successfully employed for treating pain during labor. We conjectured that intermittent sevoflurane administration would be effective for pain relief during labor without side effects to the mother or fetus. Fifty parturients breathed a mixture of 2-3% sevoflurane, oxygen and air before each uterine contraction began. The patients assessed the quality of analgesia by using a visual analogue scale (0-10) before the administration of sevoflurane and after each uterine contraction. All parturients but one were satisfied, demonstrating a mean visual analogue score before and after sevoflurane administration of 8.7 +/- 1.1 and 3.3 +/- 1.5, respectively. Apgar scores at 1 and 5 min were 9 (range 5-9) and 10 (range 8-10), respectively. Our findings suggest that sevoflurane could be effective for the treatment of labor pain.

Glide video laryngoscope for the management of foreign bodies impacted at the hypopharyngeal level in adults.

BACKGROUND: Cricopharyngeal foreign bodies (FBs) impaction in adults is a common clinical problem; without treatment, the sequelae may be lethal due to local and/or mediastinal infection. When direct laryngoscopy and flexible fiberoptic endoscopy are ineffective, rigid endoscopy is the method of choice requiring general anesthesia. The new video laryngoscopes represent a great advancement in the assessment of the laryngeal inlet. Aim of the study was to assess the feasibility of identifying and removing FBs impacted at crycofaringeal and upper oesophageal sphincter by the video laryngoscope. METHODS: In a period of 30 months, on an urgent basis, we systematically assessed by GlideScope® video laryngoscope all adult patients with a diagnosis of impacted crycofaringeal upper esophageal FB, after unsuccessful removal attempts in the otolaryngology or gastroenterology unit. RESULTS: Twenty-six consecutive patients were evaluated. In conscious sedation by video laryngoscope 17 FBs were identified and removed from the hypopharynx or upper esophageal sphincter. In 9 patients rigid endoscopy in general anesthesia and tracheal intubation was necessary to remove FBs impacted beyond the upper esophageal sphincter. CONCLUSION: In our experience video laryngoscope, because of the magnified vision, the better patient comfort and no requirement of general anesthesia, represents a great improvement in identifying and removing in conscious sedation even small and thin foreign bodies not recognized by radiological and otolaryngology examination and not readily detected by direct endoscopy.

The Helsinki Declaration on Patient Safety in Anesthesiology: a way forward with the European Board and the European Society of Anesthesiology.

Anesthesiology, which includes anaesthesia, perioperative care, intensive care medicine, emergency medicine and pain therapy, is acknowledged as the leading medical specialty in addressing issues of patient safety, but there is still a long way to go. Several factors pose hazards in Anesthesiology, like increasingly older and sicker patients, more complex surgical interventions, more pressure on throughput, as well as new drugs and devices. To better design educational and research strategies to improve patient safety, the European Board of Anesthesiology (EBA) and the European Society of Anesthesiology (ESA) have produced a blueprint for patient safety in Anesthesiology. This document, to be known as the Helsinki Declaration on Patient Safety in Anesthesiology, was endorsed together with the World Health Organization (WHO), the World Federation of Societies of Anesthesiologists (WFSA), and the European Patients' Federation (EPF) at the Euroanaesthesia meeting in Helsinki in June 2010. It was signed by several Presidents of National Anesthesiology Societies as well as other stakeholders. The Helsinki Declaration on Patient Safety in Anesthesiology represents a shared European view of what is necessary to improve patient safety, recommending practical steps that all anesthesiologists can include in their own clinical practice. The Italian Society of Anaesthesia, Analgesia, Reanimation and Intensive Care (SIAARTI) is looking forward to continuing work on "patient safety" issues in Europe, and to cooperating with the ESA in the best interest of European patients.

[The mandrake root and the Viennese Dioscorides]. / La radice di mandragora nel "dioscoride Viennese"

Pedanius Dioscorides of Anazarba in Cilicia lived in the first century. He was a Greek physician who served as a surgeon in Neròs army. He wrote several books on materia medica. One of his manuscripts with drawings of medicinal herbs was copied down in the fifth century. In this book on Greek Herbal, still kept in the National Library of Vienna, Dioscorides gave a detailed description of mandragora (mandrake). Over the ages, the mandrake has been endowed with a wonderful and mystical aura. Examples are superstitions regarding harvesting of the plant. While being torn from the ground, the mandrake would emit a horrible shriek, that would be fatal to the harvester who hears it. So, if someone simply pulled the plant, they would either die or go mad. To avoid that fate, the plant could be partially dug with a few remaining roots staying in the ground. Then a starved black dog was tied to the mandrake with a rope. The harvester, with plugged ears, would throw some scraps to the hungry dog. When the unsospecting animal lunged for food, the mandrake would be completely unrooted and the ensuing shriek would kill the dog and spare the man. According to different legends quoted by Theophrastus and Pliny the Elder, other dire consequences of unrooting a mandrake could be avoided by making circles around the plant on the ground with a sword and then facing west while digging. If there were a true Anaesthetic of Antiquity it would have been mandragora. Dioscorides describes how the wine made from mandragora produces anaesthesia: Using a cyathus of it on those who cannot sleep, or are grievously pained, or are being cut, or cauterized they will not feel pain. Here Dioscorides used for the first time the word anaesthesia as absence of sensation as we mean it today.

[Poisoning caused by chronic exposure to volatile anesthetics. Molecular mechanisms and risk anesthetics]. / Tossicità da esposizione cronica agli anestetici volatili. Meccanismi molecolari ed anestetici a rischio.

The possible molecular mechanisms potentially inducing occupational disease among operating room personnel were examined; and the really dangerous anaesthetic agents were identified. As concerns the molecular mechanisms of parenchymatous injury, we surveyed: those connected with free radicals and biological reactive intermediates produced during halothane and nitrous oxide biotransformation; those coming from inorganic fluoride produced during biotransformation of any halogenated anaesthetic agent, and from inorganic bromide released during halothane metabolism; and, finally, those linked to vitamin B12 inactivation from nitrous oxide. Halothane and nitrous oxide can be considered as really dangerous anaesthetic agents for operating room personnel, and enflurane as an agent with marginal toxic power. On the contrary, isoflurane is a safe, useful compound, totally devoided of viscerotoxic effects. From data examined it is possible to conclude that an isoflurane-oxygen-air anaesthesia is safe for operating room personnel more than a balanced anaesthesia with intravenous drugs and nitrous oxide as maintenance.

[Sudden infant death syndrome (SIDS): risk conditions and intervention strategies]. / Sudden infant death syndrome (SIDS): condizioni di rischio e strategie di intervento.

The term SIDS describes the unexpected and unexplained death of an apparently well infant. After congenital anomalies, SIDS is the most common cause of infant death in the industrial countries and it is the leading cause of death among infants older than 1 month. Descriptive epidemiological studies have shown a winter excess of cases and a peak of age distribution at about 3 months of age. Although many theories have been proposed to explain the etiology (i.e. fatal toxaemia, autonomic dysfunction, abnormalities of respiratory or cardiovascular control), an underlying cause for SIDS has not been identified. There are, however, a number of factors consistently associated with an elevated risk, the strongest of which are maternal smoking or exposure to substances of abuse during pregnancy, overheating and overinsulation, artificial feeding and prone sleeping position. A fall in the rate of the SIDS can be reasonably expected from changes in these risk factors, from home monitoring of infants suffering a near-SIDS episode and of siblings of SIDS victims, and from parental education programmes.

[Removal of a swallowed endotracheal tube in a neonate]. / Recupero di un tubo endotracheale neonatale deglutito.

Immediately following delivery a newborn infant was severely depressed. Because no respiratory effort was made and copious mucus was present, a Cole endotracheal tube was easily inserted into the trachea. Because of a mistaken manoeuvre for fastening the tube, the plastic adapter connection became dislodged from the tube, and the tube slipped out of trachea. The physician's gloved fingers could not maintain traction on the tube because of the excessive amount of mucus, and face mask ventilation made easier the slipping into the distal oesophagus. A second endotracheal tube was then properly placed in the trachea and the infant responded. The misplaced tube was removed from the oesophagus using a small, flexible biopsy forceps closed, advanced into the lumen of the swallowed tube under fluoroscopic vision. By opening the forceps, gripping the tube tightly from within, it was easily withdrawn. No adverse effects were observed.

Pulse oximetry during lumbar epidural anesthesia: reliability of values measured at the hand and the foot.

Pulse oximetry is dependent upon the presence of a pulsating vascular bed. The signal detection will be impaired in the presence of vasoconstriction or venous congestion, conditions which may occur readily in clinical practice. We compared the oximetric measurements (SpO2) at the hand and the foot with arterial hemoglobin saturation (SaO2) during lumbar epidural anesthesia. After administration of a crystalloid solution (20 mL/kg body weight lactated Ringer's solution), 40 adult male patients, scheduled for inguinal hernioplasty, received 15 mL of 0.50% plain bupivacaine into the lumbar epidural space. Two pulse oximeter probes were applied to the index finger and toe of the patients, and the SpO2 values were recorded continuously. Arterial hemoglobin saturation (SaO2) was measured using a co-oximeter 5 min before and 30 min after the onset of sensory block. No significant differences were detected between SaO2 (97.7%, SD 0.4%) and SpO2 basal values recorded from the hand (97.8%, SD 0.8%) and the foot (98.1%, SD 0.4%). After the onset of epidural anesthesia, a progressive decrease of SpO2 value recorded from the hand was observed: at 30 min it was 92.3% +/- 1.3% (P < 0.01 compared with baseline). At the same time, the SaO2 value was 97.5% +/- 0.9% (P < 0.01 compared with SpO2 from the hand). On the contrary, no significant difference from both basal value and SaO2 was detected in SpO2 measurements from the toe during the epidural block. In all patients intraoperative decrease of heart rate and arterial blood pressure was < or = 15% from baseline.(ABSTRACT TRUNCATED AT 250 WORDS)

[Systemic poisoning caused by percutaneous absorption of mineral spirit]. / Tossicità sistemica da assorbimento percutaneo di acquaragia minerale.

Owing to a car accident, the clothes of a injured joiner were permeated with a timber impregnating product containing 51.8% of mineral spirit (a mixture of naphthenes, aromatic and aliphatic hydrocarbons). Despite a short-lasting skin exposure (approximately 40 minutes), dermal contact has caused full thickness burns that, in their turn, have made easier the percutaneous absorption and the storage of organic solvents in subcutaneous tissue depots. Twenty-four hours later, clinical findings of neurologic involvement have arisen, that have got worse when the peripheral tissue perfusion has got better by the adequate replacement of lost blood.

Bilateral extensive skin necrosis of the lower limbs following prolonged epidural blockade.

Skin necrosis has not been described as a complication following epidural sympathetic blockade. We report a case of bilateral extensive skin necrosis of the lower limbs after a 48-hour lumbar epidural blockade in a 71-year-old patient with right hemiplegia and mitral valve regurgitation, without any preoperative clinical evidence of peripheral vascular disease or diabetes, who underwent transurethral prostatectomy.

[Midazolam, propofol, and clonidine for sedation and control of autonomic dysfunction in severe generalized tetanus]. / Midazolam, propofol e clonidina per la sedazione ed il controllo della disfunzione autonomica nel tetano generalizzato grave.

A case of severe tetanus with autonomic dysfunction is reported, describing the adequate response to continuous infusions of both propofol and midazolam, and the successful use of clonidine to control sympathetic over-activity. Tolerance was not observed during the 34 days of propofol and midazolam sedation. Continuously infused clonidine provided good control in combination with sedation and paralysis in this case, and no episodes of cardiovascular derangement were seen, possibly due to the adequate management of filling pressure. Vecuronium was a suitable and manageable muscle relaxant to control skeletal muscle spasms and to facilitate mechanical ventilation.

[Carbamate and organophosphate poisoning]. / Intossicazione da carbamati e da organo-fosfati.

Carbamate and organophosphate poisoning is a well known toxicological problem in developing countries, but still has, even in industrialized ones, a high mortality rate and a frequent invalidating outcome. Serious problems especially arise from cardiac (toxic myocarditis, QT prolongation, and other ventricular arrhythmias), muscular (intermediate syndrome, OPIDN), and neuro-behavioral (regressive psychosis, cognitive, mnesic and perceptive alterations) sequelae. Such complications, caused by direct neuronal, cardiac, and muscular damage, sneaky appear immediately after resolution of cholinergic crisis. Early establishment of antidotal (atropine + oximes) and supportive therapy, while reducing duration and seriousness of cholinergic crisis, should increase survival rates. In order to improve "quoad valetudinem" prognosis, widespread use of benzodiazepines is still recommended: such drugs antagonize some central signs and symptoms of cholinergic attack insensitive to atropine (fasciculations, muscular spasms, seizures, anxiety, psychomotor agitation). Moreover, they attenuate neuronal, cardiac, and muscular damage, caused by cholinergic overstimulation, which is responsible for invalidating outcome.

Sevoflurane provides better recovery than propofol plus fentanyl in anaesthesia for day-care surgery.

To compare ease of maintenance and recovery characteristics of sevoflurane and propofol plus fentanyl in day-care anaesthesia, 60 outpatients undergoing elective surgery of up to 3 h duration were randomized to receive sevoflurane or propofol as their primary anaesthetic. Induction was always carried out with propofol, but a fentanyl bolus 5 microg kg-1 was added in the propofol group. Anaesthesia was supplemented with up to 70% N2O. Significantly shorter times to extubation (10.03 min +/- 3.2 SD vs. 17.2 +/- 7.3; P < 0.001) and emergence (10.4 +/- 3.1 vs. 16.8 +/- 6.4; P < 0.001) were observed in the sevoflurane group. Patients treated with sevoflurane felt less confused, showed better performances in the digit symbol substitution test and achieved higher modified Aldrete scores sooner in the post-operative course. Maintenance of anaesthesia with sevoflurane produces faster emergence and recovery than propofol plus fentanyl after anaesthesia of short to intermediate duration.

A multicenter survey on anaesthesia practice in Italy.

AIM: To achieve more information on anaesthesia practice in Italy. METHODS: One questionnaire was completed for every anaesthetic procedure performed during the last week of June 1999 in 162 public hospitals selected in the northern, central and southern parts of Italy. RESULTS: A total of 12 263 anaesthetic procedures were performed during the study week in participating hospitals, extrapolating to 4 905200 anaesthetic procedures performed in Italy in 1999 (95% confidence interval, (+/-245000), with an annual rate of 8.5 anaesthetic procedures per 100 population. Children represented 12%, adults 60%, and elderly patients 28% of all studied patients. Emergency procedures were performed in 14% of cases; only 14% of cases were outpatients, but 31% of patients were discharged within 48 h after surgery. General anaesthesia was used in 65% of cases (45% volatile and 20% intravenous anaesthesia), regional anaesthesia in 24%, local anaesthesia in 8.8% and monitored anaesthesia care in 2.2%. No differences in the distribution of anaesthesia techniques were observed according to the geographic region or hospital size. CONCLUSION: Some organizational problems still remain to be implemented, including the development of proper preoperative evaluation clinics and postanaesthesia care units, especially in bigger hospitals with more than 1 000 beds.

A clinical diagnosis of inadvertent epidural administration of potassium chloride.

We present a case of accidental epidural administration of potassium chloride, which was diagnosed by clinical signs. The genesis of symptoms and signs following such administration is discussed and compared with other published reports.

[Effects of nitrous oxide on the female gonad in the rat]. / Effetti del protossido di azoto sulla gonade femminile nel ratto.

Female rats have been exposed (24 hours for 15 days) to N2O 60% in normo-oxic blend of N2 and O2. Vaginal smears have been observed daily. At the end of the experiment the ovaries have been removed and the following morphological parameters have been statistically evaluated: number of evolutive follicles and corpora lutea, amount of interstitial tissue. Our results seem to account for a remarkable toxic effect of N2O on the rat gonad. Such effect is testified by alterations of the oestrous cycle and, at the ovary, a decrease in the number of evolutive follicles and functioning corpora lutea and by a sharp increase of atretic phenomena.