An Teunkens

Combined spinal-epidural anesthesia for cesarean delivery: dose-dependent effects of hyperbaric bupivacaine on maternal hemodynamics.

Hypotension remains an important side effect of spinal anesthesia for cesarean delivery. There is limited evidence that reducing the spinal dose has a favorable effect on maternal hemodynamic stability. We designed the present randomized trial to test the hypothesis that reducing the spinal dose of local anesthetics results in equally effective anesthesia and less maternal hypotension. Fifty term pregnant patients were randomly assigned to two study groups. In the HIGH-group combined spinal-epidural anesthesia was performed using 9.5 mg hyperbaric bupivacaine combined with 2.5 &mgr;g sufentanil. In the LOW-group combined spinal-epidural anesthesia was performed using 6.5 mg hyperbaric bupivacaine combined with 2.5 &mgr;g sufentanil. Demographic data, obstetrical data, visual analog scale score for pain, number of medical interventions for pain, maternal hemodynamics, and neonatal outcome were recorded. Patients in the HIGH-group experienced more pronounced and longer hypotensive periods as compared with the LOW-group. The mean lowest recorded systolic blood pressure was higher in the LOW-group (102 ± 16 versus 88 ± 16 in the HIGH-group; P < 0.05). More patients in the HIGH-group experienced hypotension compared with the LOW-group (68% versus 16%; P < 0.05). In the HIGH-group 15 patients required pharmacological treatment for hypotension compared with 5 in the LOW-group. Duration of effective anesthesia (block to cold sensation above or at T3) was longer in the HIGH-group as compared with the LOW-group (95 ± 25 versus 68 ± 18 min, respectively, P < 0.05). We conclude that small-dose spinal anesthesia (6.5 mg hyperbaric bupivacaine combined with sufentanil) better preserves maternal hemodynamic stability with equally effective anesthesia that is of shorter duration.

Remifentanil for fetal immobilization and maternal sedation during fetoscopic surgery: a randomized, double-blind comparison with diazepam.

Obstetric endoscopy procedures are routinely performed at our institution to treat selected complications of monochorionic twin gestation. We perform these procedures under combined spinal epidural anesthesia plus maternal sedation. In the absence of general anesthesia, fetal immobilization is not achieved. We hypothesized that remifentanil would induce adequate maternal sedation and provide fetal immobilization, which is equal or superior to that induced by diazepam. Fifty-four second trimester pregnant women were included in this randomized, double-blind trial. After combined spinal epidural anesthesia, maternal sedation was initiated using either incremental doses of diazepam or a continuous infusion of remifentanil. Maternal sedation, hemodynamics, side effects, and fetal hemodynamics and immobilization were evaluated before, during, and for 60 min after surgery. Remifentanil produced adequate maternal sedation with mild but clinically irrelevant respiratory depression (respiratory rate 13 ± 4 breaths/min and Pco2 38.6 ± 4 mm Hg at 40 min of surgery), whereas diazepam resulted in a more pronounced maternal sedation but no respiratory depression (respiratory rate 18 ± 3 breaths/min and Pco2 32.7 ± 3 mm Hg at 40 min of surgery). Compared with diazepam, fetal immobilization with remifentanil occurred faster and was more pronounced, resulting in improved surgical conditions; the number of gross body and limb movements was 12 ± 4 (diazepam) versus 2 ± 1 (remifentanil) at 40 min of surgery. Because of this, the mean (range) duration of surgery was significantly shorter in the remifentanil-treated patients, 60 (54–71) min versus 80 (60–90) min in the diazepam group. We conclude that remifentanil produces improved fetal immobilization with good maternal sedation and only minimal effects on maternal respiration.

Intrathecal clonidine prolongs labour analgesia but worsens fetal outcome: a pilot study

PurposeIntrathecal clonidine prolongs total duration of spinal bupivacaine analgesia. However, there are contradictory reports about its effect on maternal blood pressure and only limited data are available on fetal and neonatal outcome. In this study we evaluated the efficacy of spinal clonidine combined with ropivacaine and sufentanil and its effects on maternal and fetal outcome.MethodsFifty patients requesting combined spinal epidural analgesia for labour pain relief were randomly assigned to receive intrathecal ropivacaine 3 mg, sufentanil 1.5 μg with or without clonidine 30 μg. Onset time and duration of analgesia, visual analogue scores for pain, blood pressure, ephedrine requirements, heart rate, incidence of nausea, pruritus and motor blockade, umbilical artery pH, fetal heart rate abnormalities and Apgar scores were noted and analyzed.ResultsPatients receiving spinal clonidine had significantly longer lasting analgesia compared to patients treated without clonidine (122 ± 56 min vs 90 ± 36 min, P < 0.05). Clonidine-treated patients experienced a more pronounced decrease in mean arterial pressure as compared to patients treated without clonidine (25 ± 10% vs 15 ± 12%, P < 0.05). The groups also differed in ephedrine requirement (4.91 mg vs 0.75 mg, P < 0.05), number of new onset fetal heart rate abnormalities (28% vs 0%, P < 0.05) and umbilical artery pH (7.219 ± 0.096 vs 7.289 ± 0.085, P < 0.05).ConclusionIntrathecal clonidine prolongs spinal analgesia with ropivacaine and sufentanil at the expense of maternal hypotension, worse fetal well being and worse neonatal umbilical artery pH. We do not recommend routine administration of spinal clonidine 30μg to sufentanil and ropivacaine for labour pain relief.RésuméObjectifLa clonidine intrathécale prolonge la durée totale de la rachianalgésie avec bupivacaïne. Cependant, les résultats sont contradictoires au sujet de ses effets sur la tension artérielle maternelle et il n’y a que des données limitées sur l’évolution fœtale et néonatale. Nous voulions évaluer l’efficacité d’une rachianalgésie avec donidine, ajoutée à la ropivacaïne et au sufentanil, et ses effets sur l’évolution maternelle et fœtale.MéthodeCinquante patientes désirant une analgésie rachidienne et péridurale combinée pendant le travail ont été réparties au hasard et ont reçu 3 mg de ropivacaïne intrathécaie, 1,5 μg de sufentanil avec ou sans 30 μg de clonidine. Le délai d’installation et la durée de l’analgésie, les scores de douleur selon une échelle visuelle analogique, la tension artérielle, les besoins d’éphédrine, la fréquence cardiaque, l’incidence de nausées, le prurit et le blocage moteur, le pH de l’artère ombilicale, les anomalies de la fréquence cardiaque fœtale et l’indice d’Apgar ont été notés et analysés.RésultatsLanalgésie avec clonidine rachidienne a duré significativement plus longtemps comparée à l’analgésie sans clonidine (122 ± 56 min vs 90 ± 36 min, P < 0,05). Les patientes traitées à la clonidine, comparées aux patientes sans clonidine, ont présenté une baisse plus prononcée de la tension artérielle moyenne (25 ± 10 % vs 15 ± 12 %, P < 0,05). Des différences intergroupes ont aussi été notées quant aux besoins d’éphédrine (4,91 mg vs 0,75 mg, P < 0,05), au nombre d’anomalies de la fréquence cardiaque fœtale nouvellement installées (28 % vs 0%, P < 0,05) et au pH de l’artère ombilicale (7,219 ±0,096 vs 7,289 ± 0,085, P < 0,05).ConclusionLa clonidine intrathécaie prolonge la rachianalgésie avec ropivacaïne et sufentanil aux dépens de l’hypotension maternelle, d’une dégradation du bienêtre fœtal et d’une modification du pH néonatal de l’artère ombilicale. L’administration rachidienne régulière de 30 μg de donidine n’est pas recommandée comme supplément au sufentanil et à la ropivacaïne pendant le travail obstétrical.

Low-dose combined spinal-epidural anaesthesia vs. conventional epidural anaesthesia for Caesarean section in pre-eclampsia: a retrospective analysis.

Background and objective: Epidural anaesthesia is the preferred technique of anaesthesia for Caesarean section in pre-eclampsia. Spinal anaesthesia is considered by some as a safe and effective alternative, which is especially useful in emergency situations. Combined spinal-epidural anaesthesia, using low doses of local anaesthetics with opioids, is effective and reduces the incidence of hypotension in normal pregnancy. We performed a retrospective chart analysis to evaluate the effects of combined spinal-epidural anaesthesia on maternal haemodynamics and fetal outcome compared to conventional epidural anaesthesia. Methods: A retrospective anaesthesia chart analysis of all pre-eclamptic patients who underwent Caesarean section over a 4 yr period was performed. Patient characteristic, obstetric, haemodynamic, fetal and neonatal data were gathered and analysed according to the anaesthetic technique used. Results: Seventy-seven pre-eclamptic parturients undergoing Caesarean section were identified (26 women were severely pre-eclamptic and 51 demonstrated mild pre-eclampsia). Epidural anaesthesia was performed in 62 patients and combined spinal-epidural anaesthesia was performed in 15. No differences in patient characteristic and obstetric data were noted. Highest mean arterial pressure prior to anaesthesia was comparable between the groups (epidural: 106 ± 12 vs. combined spinal-epidural anaesthesia: 109 ± 18 mmHg) as well as the lowest recorded mean arterial pressure following anaesthesia (epidural: 93 ± 13 vs. combined spinal-epidural anaesthesia: 98 ± 17 mmHg). In the combined spinal-epidural anaesthesia group more ephedrine was used compared to the epidural group (14.6 ± 4.4 vs. 3.6 ± 4.6 mg, P < 0.05). However, more lactated Ringers was used in the epidural group. Umbilical artery pH was lower in the epidural group (7.26 ± 0.01 vs. 7.29 ± 0.02, P < 0.05). Similar results were noted in 26 severely pre-eclamptic patients. Seven women underwent combined spinal-epidural anaesthesia and 19 underwent epidural anaesthesia in the severely pre-eclamptic group. Also more ephedrine was used in the combined spinal-epidural anaesthesia group. A tendency towards a lower umbilical artery pH was observed in the epidural group but this difference did not reach statistical significance. Conclusions: Combined spinal-epidural anaesthesia appears to be safe as anaesthetic technique for pre-eclampsia and severe pre-eclampsia. However, it is important to consider the retrospective design of the study and the large number of epidural anaesthetics performed.

Systemic Lidocaine Fails to Improve Postoperative Pain, But Reduces Time to Discharge Readiness in Patients Undergoing Laparoscopic Sterilization in Day-Case Surgery: A Double-Blind, Randomized, Placebo-Controlled Trial.

Background and Objectives Perioperative systemic lidocaine provides postoperative analgesia, decreases opioid consumption, and facilitates rehabilitation in abdominal surgery. We hypothesized that systemic lidocaine has analgesic effects in women undergoing day-case laparoscopic sterilization. Methods Eighty women were randomized in this prospective, double-blind trial to receive either lidocaine (intravenous bolus of 1.5 mg/kg at induction of anesthesia, followed by an infusion of 1.5 mg · kg−1 · h−1, which was continued until 30 minutes after arrival at the postanesthesia care unit [PACU]) or placebo. The primary end point was the proportion of patients with a numeric rating scale (NRS) of greater than 3, 30 minutes after arrival at the PACU. Secondary outcomes included total opioid consumption, postoperative pain scores, incidence of postoperative nausea and vomiting, and time to readiness for discharge. This clinical trial was registered (Eudra CT 2011-001315-31). Results Thirty minutes after PACU admission, the proportion of patients with an NRS score of greater than 3 did not differ between the groups (lidocaine group: 59% vs placebo group: 58%). The postoperative NRS for pain over the entire observation period was not significantly different between lidocaine and placebo groups (mean, 3.1 [SD, 0.7] vs 2.8 [SD, 0.6]; P = 0.4). Groups did not differ with respect to perioperative opioid consumption. Patients in the placebo group suffered significantly less from nausea (NRS: 0.1 [SD, 0.1] [placebo] vs 0.3 [SD, 0.1] [lidocaine]; P = 0.02) and required less postoperative nausea and vomiting rescue medication (1 patient in the placebo group vs 7 in the lidocaine group; P = 0.03). The time to meet hospital discharge criteria was significantly lower in the lidocaine group (median, 177 minutes [range, 96–408 minutes] vs 221 minutes [range, 121–420 minutes]; P = 0.02). The mean lidocaine plasma levels at the end of IV lidocaine infusion was 2.5 (SD, 1.1) &mgr;g/mL. Conclusions In laparoscopic sterilization, systemic lidocaine reduces time to readiness for hospital discharge.

Comparison of 2-Chloroprocaine, Bupivacaine and Lidocaine for spinal anesthesia in patients undergoing knee arthroscopy in an outpatient setting. A double-blind randomized controlled trial

Background and Objectives Knee arthroscopy is a well-established procedure in day-case surgery, which is frequently performed under spinal anesthesia. It is, however, controversial whether the choice for a specific local anesthetic translates into relevant outcomes. We hypothesized that the use of 2-chloroprocaine would be associated with a faster recovery from sensorimotor block. Methods Ninety-nine patients were included in this prospective, double-blind, randomized controlled trial and randomly allocated to receive either 40 mg 2-chloroprocaine, 40 mg lidocaine, or 7.5 mg bupivacaine. The primary endpoint was the time until complete recovery of sensory block. Secondary endpoints included time to recovery from motor block, failure rates, incidence of hypotension/bradycardia, postoperative pain, first mobilization, voiding and discharge times, and the incidence of transient neurologic symptoms. This clinical trial was registered prior to patient enrollment (EudraCT 2011-003675-11). Results Patients in the chloroprocaine group had a significantly shorter time until recovery from sensory block (median, 2.6 hours; interquartile range [IQR], 2.2–2.9 hours) than patients in the lidocaine group (3.1 hours; IQR, 2.7–3.6 hours; P < 0.006) and in the bupivacaine group (6.1 hours; IQR, 5.5 hours to undefined hours; P < 0.0001). Chloroprocaine was associated with a significantly faster recovery from motor block than lidocaine and bupivacaine. Times to first mobilization, voiding, and discharge were significantly shorter for chloroprocaine when compared with bupivacaine, but not with lidocaine. In the bupivacaine group, patients needed significantly less rescue medication for postoperative pain when compared with lidocaine and chloroprocaine. Groups did not differ with respect to patient satisfaction, incidence of bradycardia/hypotension, and transient neurologic symptom rate. Conclusions For spinal anesthesia in patients undergoing ambulatory knee arthroscopy, chloroprocaine has the shortest time to complete recovery of sensory and motor block compared with bupivacaine and lidocaine.

Alizapride and ondansetron for the prevention of postoperative nausea and vomiting in patients undergoing laparoscopic gynaecological surgery: A double-blind, randomised, placebo-controlled noninferiority study.

BACKGROUND Postoperative nausea and vomiting (PONV) can be prevented. Alizapride is an established antiemetic that may be effective in this role. OBJECTIVE Our primary objective was to test the hypothesis that alizapride is noninferior to ondansetron for the prophylaxis of PONV. DESIGN A randomised, placebo-controlled, double-blinded noninferiority study. SETTING University hospitals of Leuven, Belgium, from November 2008 to July 2011. PATIENTS A total of 523 patients undergoing laparoscopic gynaecological surgery were included in the study. Reasons for exclusion were American Society of Anesthesiologists (ASA) greater than 2, hypersensitivity to the study medication, pregnancy, mental disorders, psychiatric illness or consumption of antiemetic drugs within 24 h before initiation of the study. INTERVENTION Patients received either alizapride 100 mg, ondansetron 4 mg or placebo intravenously 30 min before the end of surgery. MAIN OUTCOME MEASURES The main outcome measures included the incidences of postoperative nausea (PON) and postoperative vomiting (POV) during the stay in the postanaesthetic care unit (PACU), with noninferiority testing for alizapride versus ondansetron. The region of noninferiority was defined as a relative difference in incidence of 25%. Secondary outcome was the incidence of PONV in the PACU and after 24 h. RESULTS In the alizapride group, 32% of the patients experienced PON during the PACU stay, compared with 28% in the ondansetron group [relative risk 1.13, 90% confidence interval (CI) 0.87 to 1.46], exceeding the predefined margin of noninferiority. With respect to the incidences of POV during the PACU stay, 12.8% of the patients randomised to receive alizapride experienced POV, compared with 7.7% of who received ondansetron (relative risk 1.67, 90% CI 1.00 to 2.87). The incidences of PON and POV in the placebo group during the PACU stay were 34.2 and 9.8%, respectively. The 24-h incidences of PONV were lower than expected in this high-risk group of patients and were similar at 39.3, 36.8 and 31.5% in the placebo, alizapride and ondansetron groups, respectively (&khgr;2, P = 0.36). Patients treated with ondansetron required significantly less rescue medication than placebo-treated patients (P = 0.035). Due to the lower than expected incidences of PONV in this study, the power to conclude any noninferiority of alizapride was reduced to only 41%. CONCLUSION We found no evidence to support the noninferiority of alizapride 100 mg when compared with ondansetron 4 mg for the intraoperative prophylaxis of PONV. However, the lower than expected incidences of PONV reduced the power of this study to conclude noninferiority or confirm significant beneficial effects for either antiemetic for PON and POV during the PACU stay. TRIAL REGISTRATION Eudra CT 2008-004789-20

Simplified algorithm for the prevention of postoperative nausea and vomiting: a before-and-after study

Background: Poor adherence to guidelines aimed at reducing the incidence of postoperative nausea and vomiting (PONV) is well known. In a before‐and‐after study, we tested the effectiveness of a simplified algorithm for PONV prophylaxis on the incidence of PONV. Methods: In the first audit, we examined the adherence to our institutional guidelines for PONV prevention. In response to the results of this audit, we introduced a simplified algorithm for PONV prevention [female patients receiving triple prophylaxis (dexamethasone and ondansetron plus either a target‐controlled infusion with propofol or droperidol) and male patients receiving double prophylaxis, dexamethasone, and ondansetron]. The impact of the simplification of the PONV algorithm was evaluated in a second audit. In both audits, we reviewed the medical records of all adult patients undergoing elective non‐cardiac non‐day‐case surgery under general anaesthesia and being admitted to our post‐anaesthesia care unit during two arbitrarily chosen weeks. We assessed the incidence of nausea, vomiting, and PONV after 1 and 24 h, and the compliance with the departmental algorithm for PONV prophylaxis. Results: After simplification of the PONV algorithm, the overall incidence of PONV within 24 h after surgery was significantly lower than before the implementation of the simplified PONV algorithm (22% vs 33%, P=0.02). The PONV incidence within 1 h was comparable between the audits (11% vs 14%, P=0.45). The adherence to departmental guidelines for PONV prophylaxis was significantly higher after the implementation of the simplified PONV algorithm (46% vs 18%, P=0.0001). Conclusions: A simplified algorithm for PONV prophylaxis resulted in a significant reduction in the PONV incidence and better compliance with the PONV algorithm.

Does spinal chloroprocaine pharmacokinetic profile actually translate into a clinical advantage in terms of clinical outcomes when compared to low-dose spinal bupivacaine? A systematic review and meta-analysis

STUDY OBJECTIVE Spinal anesthesia is well suited for day-care surgery, however a persisting motor block after surgery can delay discharge. Among the new drugs available, chloroprocaine has been associated with a short onset time, and motor block duration and a quicker discharge. However, it is not clear if those outcomes are clinically significantly superior compared to those associated with the use of low-dose hyperbaric bupivacaine. DESIGN Aim of the study was to determine if spinal 2-chloroprocaine was superior to low-dose spinal bupivacaine regarding the following outcomes: onset time, block duration, time to ambulation and time to discharge. PATIENTS/INTERVENTIONS We performed a systematic literature search of the last 30 years using PubMed Embase and the Cochrane Controlled Trials Register. We included only blinded, prospective trials comparing chloroprocaine with a low dose of bupivacaine for spinal anesthesia. Low dose bupivacaine was defined as a dose of 10 mg or less. Outcomes of interest were time to motor block regression (primary outcome), time to ambulation and time to discharge (secondary outcomes), as indirect indicators of a complete recovery after spinal anesthesia. MAIN RESULTS Compared to a low dose bupivacaine, spinal 2-chloroprocaine was associated with significantly faster motor and sensory block regression (pMD = -57 min-140.3 min; P = 0.015 and <0.001 respectively), a significantly shorter time to ambulation and an earlier discharge (pMD = -84.6 min; P < 0.001 and pMD = -88.6 min and <0.001 respectively). Onset time did not differ between the two drugs (pMD = -1.1 min; P = 0.118). CONCLUSIONS Spinal 2-chloroprocaine has a shorter motor block duration, a significantly quicker time to ambulation and time to discharge compared to low dose hyperbaric bupivacaine and may be advantageous when spinal anesthesia is performed for day case surgery.

Dorsal penile nerve block for circumcision in pediatric patients: A prospective, observer-blinded, randomized controlled clinical trial for the comparison of ultrasound-guided vs landmark technique

Circumcision is a frequently performed procedure in day case pediatric surgery. Dorsal penile nerve block has proven its effectiveness for the management of acute postoperative pain after circumcision. We investigated if the ultrasound‐guided placement of a dorsal penile nerve block could reduce opioid requirement as compared to a landmark‐based technique.