Intrapartum sonography for occiput posterior detection in early low dose combined spinal epidural analgesia by sufentanil and ropivacaine.

AIM: To evaluate the incidence of occiput posterior position in labour with and without combined spinal epidural analgesia (CSE) by low dose of sufentanyl and ropivacaine. MATERIAL AND METHODS: This study focused on 132 women subdivided in two groups, patients in spontaneous and in labour analgesia, administered by a low dose CSE by sufentanyl and ropivacaine; all women were evaluated by digital examinations and ultrasound till delivery. All data were collected and analyzed by an independent reviewer. RESULTS: In the second stage, 79 were persistent occiput posterior position (POPP) fetuses and 36 were translated from anterior to posterior position (TAPP) fetuses. Specifically, in spontaneous labour on 25 women in anterior position, there were 17 TAPP and in CSE analgesia on 28 women in anterior, there were 19 in TAPP, without significant differences. The number of asynclitisms was higher in the POPP group (84%) respect to the TAPP group (75%), so as the rate of caesarean section (67% versus 52.7%). CONCLUSIONS: The labour with low dose of ropivacaine and sufentanyl does not increase the occiput posterior position during fetal descent, leading to a POPP. Finally, since in the occiput anterior presentation labour analgesia significantly lengthens time to delivery, in the occiput posterior position this is significantly increased, with a prolonged second stage of labour and reduced time of descent of fetal head in obstetric pelvis.

Adding sufentanil to levobupivacaine or ropivacaine intrathecal anaesthesia affects the minimum local anaesthetic dose required.

BACKGROUND: We carried out this prospective, randomized, double-blind study in order to evaluate whether the intrathecal addition of sufentanil 3.3 mcg affects both the minimum local anaesthetic dose (MLAD) of spinal levobupivacaine and ropivacaine for a caesarean section and enhances the spinal block characteristics. METHODS: One hundred and eighty women were randomly allocated into four groups: levobupivacaine (Group L), levobupivacaine plus sufentanil (Group L+S), ropivacaine (Group R) and ropivacaine plus sufentanil (Group R+S). Each received 3 ml of the study solution intrathecally as part of a combined spinal/epidural technique. The initial dose was 12 mg for Groups L and L+S, and 15 mg for Groups R and R+S. The test solution was required to achieve a visual analogue pain score (VAPS) of 30 mm or less to be considered effective at skin incision, uterine incision, birth, peritoneal closure and at the conclusion of surgery. Effective or ineffective responses determined a 0.5 mg decrease or increase of the same drug, respectively, for the next patient in the same group, using an up-down sequential allocation. RESULTS: Using the Dixon and Massey formula, the MLAD was 10.65 mg [confidence interval (CI) 95%: 10.14-11.56] in Group L, 4.73 mg (CI 95%: 4.39-5.07) in Group L+S, 14.12 mg (CI 95%: 13.50-14.60) in Group R and 6.44 mg (CI 95%: 5.86-7.02) in Group R+S. CONCLUSIONS: The addition of sufentanil reduced the MLAD of both the local anaesthetics. It did not affect their potency ratio significantly and resulted in enhanced spinal anaesthesia.

Long-term epidural analgesia treatment in pre-eclamptic women: a preliminary trial.

Pre-eclampsia (PE) is a clinical pregnancy-related condition, characterised by an elevated blood pressure and proteinuria. The author treated selected cases of PE with long-term epidural analgesia (LTEA), that reduced labour pain and operated directly on the PE aetiopathogenesis, not on the symptoms. A total of 15 women with PE were hospitalised at 35-37 weeks of pregnancy, checked for blood pressure, liver and renal function, platelet count and had an epidural catheter inserted for a continuous administration of an analgesic mixture of Naropin, Sufentanil and Clonidine. The average weeks at delivery were 37 weeks and 1 day; 10 women had a spontaneous delivery and five a caesarean section: the mean birth weight was 2,906 g and the Apgar scores at 1 min and 5 min exceeded 7 in all cases. All the parameters improved after hospital admission and at discharge. All the patients were discharged in good condition and no patients needed supplementary antihypertensive treatment. The LTEA utilisation for 1 week is well tolerated and improves uteroplacental perfusion, but further studies and a larger number of patients are required to evaluate this pharmacological procedure and determine its place in the management of PE.

Autotransfusion with predeposit-haemodilution and perioperative blood salvage: 20 years of experience. Rizzoli Study Group on Orthopaedic Anesthesia.

BACKGROUND: Through a prospective study, we evaluated the efficacy of an integrated autotransfusion regimen comprised of predeposit-hemodiluition and intra and post-operative blood salvage in major orthopaedic surgery. METHODS: We examined the records of 2303 consecutive patients (1524 females and 779 males, mean age 62.7, standard deviation 11 years (range 16-90 yrs), pre-operative haemoglobin (Hb) concentration 13.5 (SD 1.4) (range 6.7-19.3) g/dl undergong total hip arthroplasty (THA 1582 patients), THA after the removal of internal fixation devices (RFD+THA, 25 patients), total knee arthroplasty (TKA, 347 patients), revision surgery of the hip (HR, cup+stem revision, 248 patients; cup revision 64 patients; stem revision 23 patients) and total knee revision (TKR 14 patients). We estimated that the number of predonations (MSBOS - maximum surgery blood order schedule) was 2 units for THA, TKA and TKR, and 3 units for partial or total hip revision and for total hip arthroplasty with fixation removal. RESULTS: It was possible to obtain the MSBOS in 2070 patients (89.8%). Homologous red blood cell (HRBC) transfusion were carried out in 184 patients (8%). We found that the need to use HRBC was significantly associated with failure to meet the number of MSBOS, female sex, lower pre-operative Hb concentration, use of calcium heparin for antithrombosis prophylaxis, more extensive surgery, a higher ASA rating and co-existing diseases such as coronary artery disease. CONCLUSIONS: Cooperation among anaesthesis, transfusionists and surgeons in the application of an integrated autotransfusion regimen enabled us to treat 92% of our patients with only autotransfusion.

A comparison between low-dose ropivacaine and bupivacaine at equianalgesic concentrations for epidural analgesia during the first stage of labor.

The aim of this study was to evaluate the efficacy, onset and duration of analgesia of two equianalgesic epidural doses of ropivacaine and bupivacaine during the first stage of labor. The study included 190 healthy nulliparous parturients who presented spontaneous onset of labor and required epidural analgesia. They were divided randomly to receive epidural analgesia with an initial dose 0.10% ropivacaine or 0.0625% bupivacaine 20 mL both with the addition of 10 microg of sufentanil. There were no significant differences in onset time, quality of analgesia, maternal hypotension and ability to ambulate. Ropivacaine produced more prolonged analgesia then bupivacaine (89 vs 119 min;P<0.0003). The clinical value of this prolonged analgesia after the first dose needs further evaluation when a continuous infusion technique is used.

Anatomy of the lumbar epidural region using magnetic resonance imaging: a study of dimensions and a comparison of two postures.

Many techniques used to investigate the epidural region may alter the anatomy. Magnetic resonance imaging (MRI) has been introduced as a non-invasive diagnostic technique. The aim of this study was to investigate the anatomy of the lumbar epidural region using MRI, studying the morphology, the dimensions and the modification that may result from a change of position. Ten young, healthy female volunteers were studied to obtain results relevant to obstetric anesthesia. The following measurements were made: anterior epidural space (AES); posterior epidural space (PES); ligamenta flava; distance between the PES and the skin (S-ES); and interspace distance (ISD). All these distances were measured with the subject supine and the lumbar spine either in a neutral or a non-lordotic (flexed) position. The S-ES ranged from 2.7 to 8.1 cm. This distance was greater in the lower than in the upper lumbar segments. No differences were observed in AES, PES and ligamenta flava between the neutral and flexed positions. Flexion of the spine did not affect the S-ES but increased the ISD (P < 0.05). The S-ES at any lumbar segment or interspace and the thickness of ligamenta flava at the L2/3 interspace correlated significantly with body weight (respectively, P < 0.01 and P < 0.02). In conclusion, MRI may clearly reveal the anatomy of the epidural region. The circumferentially and metamerically segmented compartments of the epidural space were clearly noted and measured. Ligamenta flava seem to be thinner in younger than in older subjects. This may partly explain a reduced loss of resistance sometimes perceived in obstetric patients.

Comparison of fentanyl with clonidine as adjuvants for epidural analgesia with 0.125% bupivacaine in the first stage of labor: a preliminary report.

48 primiparae received epidural analgesia in labor with 10 ml of 0.125% bupivacaine with epinephrine 1:800 000, and then were divided in 4 equal groups (n = 12) to receive one of the following: 5 ml saline (B); 100 mug of fentanyl (BF); 150 microg of clonidine (BC); 75 microg of clonidine and 50 microg of fentanyl (BCF). All the patients had satisfactory analgesia. Onset was similar in the 4 groups but the duration of analgesia was significantly prolonged by the addition of either 100 microg of fentanyl or 150 microg of clonidine (respectively 89.8 min and 92.5 min vs 62.5 min) (P < 0.0001). The addition of both clonidine (75 microg) and fentanyl (50 microg) produced a considerably prolonged analgesia (177.5 min) (P < 0.0001). No episodes of bradycardia were observed. Hypotension, reversed by i.v. ephedrine, occurred in 2 patients of BCF group and in 1 patient of BF and BC groups. Only patients receiving fentanyl had pruritus. Both fentanyl and clonidine produced sedation, but both incidence and severity were greater with the mixture. No differences in neonatal outcome assessed by Apgar scores and NACS, were observed.

Propofol and thiopentone for caesarean section revisited: maternal effects and neonatal outcome.

In 56 women undergoing elective caesarean section, general anaesthesia was induced with either propofol 1% or thiopentone 2.5% followed by 50% nitrous oxide in oxygen and isoflurane 0.75% until delivery. In the thiopentone group the arterial pressure rose following tracheal intubation and skin incision, while in the propofol group there was a significant tendency to hypotension immediately following induction of anaesthesia. There were differences in electroencephalogram (EEG) between the groups, while laryngoscopy, intubation and surgical stimulation had no effect on EEG pattern. Recovery after anaesthesia did not differ between groups. None of the patients had recall of the intraoperative period, but 53% of patients induced with propofol showed signs of light anaesthesia between induction and delivery. Neonates in the propofol group had lower Apgar scores 1 min after birth than those in the thiopentone group, but these differences were no longer significant at 5 min. No differences were noted in neurobehavioural status at 1, 4 and 24 h.

Maternal expectations and experiences of labour pain and analgesia: a multicentre study of nulliparous women.

Six hospitals with large maternity units in five different European countries were involved in this multicentre study. At least 100 primiparae for each country were examined. All mothers received two standardized interviews, one during the last month of pregnancy, and one 24 h after delivery. Maternal expectations and experiences of pain, pain relief, and satisfaction with analgesia and childbirth were assessed by a 100 mm visual analogue scale (VAS). Almost all mothers were seen regularly by an obstetrician or a midwife during pregnancy, had prepared childbirth classes and received antenatal information on labor analgesia techniques. Differences between the five groups were noted in the level of education and socio-economic status. Maternal expectations of labor pain and the answers to the pre-delivery interview varied significantly between the centers, as did maternal knowledge, expectation and ultimate choice of analgesic technique. Generally speaking the level of maternal satisfaction with analgesia and childbirth experience was high; however, epidural analgesia was more effective than other methods of pain relief (P<0.0001). The most satisfied mothers were those who expected more pain, were satisfied with the analgesia received and had good pain relief after analgesia (P<0.001).

Which induction drug for cesarean section? A comparison of thiopental sodium, propofol, and midazolam.

STUDY OBJECTIVE: To determine maternal and neonatal effects of three different induction drugs (thiopental sodium, propofol, and midazolam) for cesarean section. DESIGN: Randomized, double-blind study. SETTING: Inpatient obstetric department at a general hospital. PATIENTS: 90 healthy patients undergoing elective cesarean section with general anesthesia. INTERVENTIONS: 3 groups of 30 patients each receiving thiopental 5 mg/kg, propofol 2.4 mg/kg, or midazolam 0.3 mg/kg for induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: Time to induce anesthesia, hemodynamic changes, depth of anesthesia, recovery after anesthesia, placental transfer, and neonatal outcome (Apgar and neurobehavioral examinations) were studied. In the thiopental and midazolam groups, systolic blood pressure and heart rate rose following endotracheal intubation and skin incision (p < 0.001 and p < 0.0025, respectively), while in the propofol group, there was significant hypotension after induction (p < 0.005). Electroencephalographic patterns showed a light depth of anesthesia with propofol and midazolam between anesthesia induction and delivery, confirmed by the presence of clinical signs of light anesthesia in 50% of propofol patients and 43% of midazolam patients. Time to induce anesthesia was longer with midazolam (p < 0.0001). Neonates in the midazolam and propofol groups had lower Apgar and neurobehavioral scores than those in the thiopental group. Umbilical artery to umbilical vein ratios were above 1 in the propofol and midazolam groups. CONCLUSION: Thiopental still remains the first-choice induction drug for cesarean section. The slow induction time with midazolam may put the mother at risk for pulmonary inhalation. A plane of anesthesia that may risk awareness and potential neonatal depression is the main drawback of the two newer induction drugs.

Epidural mepivacaine for cesarean section: effects of a pH-adjusted solution.

STUDY OBJECTIVE: To determine the clinical effects of the alkalinization of 2% mepivacaine with epinephrine used for epidural block during cesarean section. DESIGN: Randomized, double-blind, placebo-controlled (standard commercial preparation of 2% mepivacaine with epinephrine) study. SETTING: Inpatient obstetric department at a general hospital. PATIENTS: Seventy patients scheduled for elective cesarean section under epidural anesthesia. INTERVENTIONS: Two groups of 35 patients each receiving either the standard commercial preparation of mepivacaine or the pH-adjusted solution (prepared with the addition of 0.1 meq/ml of sodium bicarbonate to the standard commercial solution). MEASUREMENTS AND MAIN RESULTS: Measurements of sensory (pinprick) and motor (Bromage's criteria) block were taken at 1- to 2-minute intervals beginning after the completion of the epidural injection. Increasing the pH of the mepivacaine resulted in a significant shortening of the time of analgesia onset (9.3 minutes compared with 16.01 minutes, p less than 0.01) and of peak effect (11.1 minutes compared with 21.2 minutes, p less than 0.01). The alkalinization did not affect duration of the block, intensity of motor block, or mean dose of local anesthetic used. CONCLUSION: The alkalinization allowed the surgery to proceed more rapidly, significantly decreasing the time interval between epidural block and delivery of the infant.

Spontaneous splenic vein aneurysm rupture in the puerperium.

A case of intra- and retroperitoneal haemorrhage after a splenic vein aneurysm rupture is described. A 27-year-old woman complained of chest pain on her first postpartum day. Symptoms were initially suggestive of pulmonary embolism, but within 3 h she developed severe acute abdominal pain, abdominal distension and haemodynamic instability. Ultrasound demonstrated a non-echogenic mass in the abdomen suggestive of a fluid collection and a computed tomography scan confirmed the presence of a lesion at the pancreatic tail. Urgent laparotomy revealed splenic vein rupture near the pancreatic tail. Partial pancreatectomy and splenectomy were performed. The patient subsequently made an uneventful recovery. Histological examination revealed a splenic vein aneurysm and chronic inflammatory changes in the pancreatic tissue. Rupture of a splenic vein aneurysm is a rare event and the diagnosis may present difficulty because its presentation is similar to several other more common conditions. However, rupture of a splenic vein aneurysm should be suspected in any pregnant woman with unexplained abdominal pain or with clear signs of haemorrhage, as delay in diagnosis can have devastating consequences.

Efficacy and comparison of 0.5% levobupivacaine with 0.75% ropivacaine for peribulbar anaesthesia in cataract surgery.

BACKGROUND AND OBJECTIVE: The low cardiovascular and neurological toxicity of levobupivacaine has led to its application as a local anaesthetic in a wide variety of specialist applications including peribulbar block for cataract surgery. The aim of this study was to evaluate the efficacy of levobupivacaine 0.5% and to compare block quality vs. ropivacaine 0.75% in peribulbar anaesthesia. METHODS: We examined 208 patients subjected to cataract surgery by phacoemulsification who were randomized into two groups according to the anaesthetic used for peribulbar block, namely levobupivacaine 0.5% or ropivacaine 0.75%, both with the addition of hyaluronidase. Nerve block was carried out by injection of 6 mL of the anaesthetic mixture equally distributed between the inferotemporal and superonasal areas. The success of the block was evaluated by determining the time of motor and sensory onset, akinesia score, times of motor and sensory offset and satisfaction of the patient and surgeon after 24 h. Pre-block, post-block and postoperative intraocular pressure as well as the duration of surgical intervention was also determined. RESULTS: With respect to ropivacaine, levobupivacaine showed a significant reduction (P < 0.001) in the average motor and sensory onset. Both the akinesia score (P < 0.01) and mean motor and sensory offset times were also higher (P < 0.001). Neither the average intervention times nor the satisfaction of the patient/surgeon showed any significant differences between the two groups. CONCLUSIONS: Levobupivacaine (0.5%) has better anaesthetic properties with respect to 0.75% ropivacaine and is well-suited for peribulbar block in cataract surgery.

Minimum local anaesthetic dose (MLAD) of intrathecal levobupivacaine and ropivacaine for Caesarean section.

We determined the minimum local anaesthetic dose (MLAD) of spinal levobupivacaine and ropivacaine for Caesarean section. Ninety women were randomly allocated to two groups and received 3 ml of study solution by a combined spinal/epidural technique. The initial dose was 12 mg for levobupivacaine and 17 mg for ropivacaine groups. To be considered effective, a test solution had to achieve a visual analogue pain score (VAPS) of 30 mm or less at skin incision, uterine incision, birth, peritoneal closure, and at the end of surgery. Effective or ineffective responses determined, respectively, a 0.3 mg decrease or increase of the same drug for the next patient in the same group, using up-down sequential allocation. The MLAD of levobupivacaine was 10.58 mg (CI 95%: 10.08-11.09) and the MLAD of ropivacaine 14.22 mg (CI 95%: 13.67-14.77), using the Dixon and Massey formula. The potency ratio between spinal levobupivacaine and spinal ropivacaine was 1.34.

Regional blocks for cesarean section.

Recent researches in the field of regional anesthesia for cesarean section have focused on spinal anesthesia, including prophylaxis of maternal hypotension, the use of opioids to improve intra- and postoperative analgesia and the use of ropivacaine.

Spinal buprenorphine for postoperative analgesia after caesarean section.

Two doses of intrathecal buprenorphine for postoperative analgesia have been compared. Forty-five women undergoing elective caesarean section under spinal anaesthesia were randomly divided into three groups. Group A (controls, n = 15) received hyperbaric bupivacaine; Groups B and C received the same but with the addition of 0.03 mg or 0.045 mg buprenorphine, respectively. Patients receiving buprenorphine had a longer pain-free interval than the controls (P less than 0.01). Within the buprenorphine groups, patients receiving the higher dose had a longer effect (420 min s.d. 24) than those receiving the lower dose (173 min s.d. 31) (P less than 0.01) without any increase in side-effects.

Epidural fentanyl plus bupivacaine 0.125 per cent for labour: analgesic effects.

Ninety-five healthy nulliparous women, ASA physical status I-II with an uncomplicated pregnancy and single fetus in vertex position were given lumbar epidural analgesia. Patients in Group A (n = 35) received bupivacaine 0.125 per cent with epinephrine 1:800.000; Groups B (n = 30) and C (n = 30) received the same agents as Group A but with the addition to the initial dose of 50 or 100 micrograms of fentanyl respectively. All patients were evaluated for duration and quality of analgesia, duration of labour, method of delivery and total dose of bupivacaine used. The addition of either 50 or 100 micrograms of fentanyl resulted in longer duration of analgesia (93 +/- 9 min and 106 +/- 8 min respectively vs 55 +/- 7) and reduced bupivacaine total doses (64 +/- 0.03 and 55 +/- 1.5 respectively vs 109.5 +/- 1.3). Only the addition of 100 micrograms of fentanyl improved significantly the quality of analgesia (43.3 per cent of excellent scores vs 6.6 per cent in Group B and 5.7 per cent in Group A). Addition of fentanyl did not affect the duration of labour, the method of delivery and the neonatal neurobehaviour scores.

IV clonidine for post-extradural shivering in parturients: a preliminary study.

We have studied the efficacy of i.v. clonidine to suppress post-extradural shivering in parturients. Forty healthy parturients who received extradural block for labour (n = 20) or for Caesarean section (n = 20) and who required treatment for shivering after delivery were allocated randomly to two groups. Group I received i.v. clonidine 30 micrograms diluted in saline to a total volume of 5 ml (therapeutic solution). This bolus was repeated every 5 min if the initial therapy produced no improvement, up to a maximum dose of 90 micrograms. Group II received saline 5 ml (placebo solution), repeated every 5 min if the initial bolus produced no improvement, up to a maximum of three boluses. After 15 min of observation, patients in group I received the placebo solution and those in group II received the study solution. All patients who received clonidine improved, and 75% ceased to shiver within 5 min after only one dose of clonidine 30 micrograms. In contrast, none of the patients treated with saline improved. When patients in the placebo group received clonidine, improvement occurred. Arterial pressure, heart rate, core and peripheral temperature and oxygen saturation did not differ significantly between and within the groups before and after administration of clonidine. We conclude that a small dose of i.v. clonidine may be useful to suppress post-extradural shivering in parturients.

[Levobupivacaine in obstetric analgesia and anaesthesia]. / La levobupivacaina in anestesia ed analgesia ostetrica.

METHODS: Published studies, including abstracts, has been reviewed and summarized. RESULTS: Studies in sheep have demonstrated no significant differences in pharmacokinetic and placental transfer of levobuvacaine when compared with bupivacaine. Clinical studies on cesarean section confirmed similar performance between these two drugs. No differences in onset time, sensory and motor block and efficacy of analgesia have been reported. Two multicentre studies on labor analgesia reported again similar analgesic efficacy with a trend toward less motor block in parturients receiving levobupivacaine. CONCLUSIONS: This review has shown that levobupivacaine has a similar efficacy and a similar maternal fetal safety to that of bupivacaine. Further studies are needed to determine if the chemical properties of the new agent may influence the sensory and motor characteristics of the block.