Brett B. Gutsche

Comparison of combined spinal-epidural and low dose epidural for labour analgesia.

Purpose: To compare the combined spinal-epidural (CSE) technique with the epidural technique with regard to time to initiate and manage, motor block, onset of analgesia and satisfaction during labour.Methods: Upon requesting analgesia, 50 healthy term parturients were randomized in a prospective, double-blind fashion to receive either CSE analgesia or lumbar epidural analgesia in the labour floor of a university hospital at an academic medical centre. The epidural group (n=24) received bupivacaine 0.0625%-fentanyl 0.0002% with 0.05 ml in 10 ml local aesthetic sodium bicarbonate 8.4% and epinephrine 1:200, 000. The CSE group (n=26) received intrathecal 25 µg fentanyl and 2.5 mg bupivacaine. Additional analgesia was provided upon maternal request.Results: There were no differences (P>0.05) in time of perform either technique, motor blockade, or parturient satisfaction or in the number of times that the anesthesiologist was called to perform any intervention. Although the first sign of analgesia was not different between the two groups, the onset of complete analgesia was more rapid with the CSE technique (Visual Analogue Pain Score (VAPS) at five minutes<three: 26/26vs 17/24,P±0.001).Conclusion: Although epidural analgesia with a low concentration of local anethetic and opioid mixture takes longer to produce complete analgesia, it is a satisfactory alternative to CSE.RésuméObjectif: Comparer l’analgésie rachidienne-péridurale combinée (RPC) à l’analgésie péridurale concernant le temsp nécessaire à la réalisation de la technique et à l’induction, le blocage moteur, le délai d’installation de l’analgésie et la satisfaction de la patiente pendant le travail obstétrical.Méthode: Au moment de la demande d’analgésie, 50 parturientes à terme réparties de façon aléatoire ont reçu soit une analgésie RPC, soit une analgésie péridurale lombaire pour participer à une étude prospective en double insu. Le groupe péridural (n=24) a reçu un mélange bupivacaïne 0,0625 %-fentanyl 0,0002 % avec un ajout de 0,05 ml (par 10 ml d’anesthésique local) de bicarbonate de sodium à 8,4 % et de l’épinéphrine 1:200 000. Le groupe RPC (n=26) a reçu une injection intrathécale de 25 µg de fentanyl et de 2,5 mg de bupivacaïne. L’analgésie supplémentaire a été administrée sur demande.Résultats: Il n’y a eu aucune différence intergroupe (P>0,05) quant au temps nécessaire à la réalisation de chacune des techniques et à l’atteinte du blocage moteur, à la satisfaction des patientes et au nombre d’interventions de l’anesthésiologiste appelé sur demande. Le premier signe d’analgésie est survenu au même temps dans les deux groupes, mais le début de l’analgésie complète est survenu plus rapidement dans le groupe RPC (Score à l’Échelle Visuelle Analogique, SEVA, à cinq minutes<trois: 26/26vs 17/24,P±0,001).Conclusion: L’analgésie péridurale complète réalisée avec une faible concentration d’anesthésique local et un mélange d’opioïdes connaît une installation plus lente que l’analgésie RPC, mais elle en constitue une solution de remplacement satisfaisante.

Comparison of three different doses of intrathecal fentanyl and sufentanil for labor analgesia

STUDY OBJECTIVE To compare the duration of analgesia and incidence of side effects of three doses of intrathecal fentanyl (25 micrograms, 37.5 micrograms, 50 micrograms) with three doses of intrathecal sufentanil (5 micrograms, 10 micrograms, 15 micrograms). DESIGN Randomized, double-blind study. SETTING Labor suite of the Hospital of the University of Pennsylvania. PATIENTS 60 ASA physical status I and II parturients in active labor who requested analgesia. INTERVENTIONS Patients received one of the six doses of opioid diluted with normal saline to achieve a volume of 1.5 ml intrathecally. MEASUREMENTS AND MAIN RESULTS Duration of analgesia, contraction pain, degree of pruritus, maternal blood pressure, maternal heart rate, fetal heart rate, Apgar scores, and neurologic and adaptive capacity scores were measured. There was no statistical difference among the doses of fentanyl in duration of analgesia. In addition, there was no statistical difference among the doses of sufentanil. The durations of analgesia for all doses of sufentanil were statistically longer than that for all doses of fentanyl. There was no difference among all the groups for maximal pruritus score. The duration of pruritus did not differ among doses of fentanyl or sufentanil; the duration of pruritus was significantly longer for sufentanil. All groups had a decrease in blood pressure. There was no difference among the groups in regard to the effect on the systolic or diastolic blood pressure. CONCLUSIONS Intrathecal sufentanil produced analgesia of longer duration than fentanyl for all doses studied. The duration of pruritus with sufentanil was also longer.

Epidural lidocaine versus 2-chloroprocaine for fetal distress requiring urgent cesarean section

Chloroprocaine is a local anesthetic widely used for the urgent cesarean delivery of a distressed fetus in an mother with a epidural catheter because of its quick onset and short half-life. However, chloroprocaine has disadvantages that include decreased effectiveness of subsequently administered epidural amides and narcotics. Lidocaine with freshly added epinephrine and sodium bicarbonate is also rapid in onset, although there is the theoretical concern regarding the accumulation of ionized lidocain in the acidotic fetus. A retrospective review revealed that though the drug administration to incision time was significantly faster (P < 0.005) for 3% chloroprocaine, both 3% chloroprocaine and 1.5% lidocaine were clinically effective. There were no differences in neonatal Apgar scores or neonatal umbilical cord pH values between the two treatment populations, offering lidocaine as an attractive alternative to chloroprocaine.

Effects of immediately initiating an epidural infusion in the combined spinal and epidural technique in nulliparous parturients

Background and Objectives: Intrathecal fentanyl with bupivacaine provides rapid labor analgesia of limited duration. We investigated the effect of initiating an epidural infusion of 0.1% ropivacaine with fentanyl 2 μg/mL and epinephrine 1:400,000 (REF) on the duration of analgesia and incidence of side effects after intrathecal injection in the combined spinal and epidural technique. Methods: Thirty‐four nulliparous parturients with a cervical dilation of 3 to 5 cm were randomized to receive epidural saline or REF at 10 mL following the intrathecal injection of fentanyl 25 μg and bupivacaine 2.5 mg. Degree of analgesia, severity of pruritus, motor block, blood pressure, and sensory level to coolness were assessed until the patient requested additional analgesia. Results: Analgesia was significantly longer in the REF group, 158.4 ± 59.6 minutes versus 103.8 ± 26.2 minutes. The decrease in blood pressure compared with the blood pressure at intrathecal injection was greater for the REF group at all times, but achieved statistical significance at 60 minutes. There was no difference in ephedrine use, pruritus, or motor block between groups. There was no difference in sensory level to coolness at 90 minutes after intrathecal injection between groups. Conclusions: Initiating an infusion of REF prolongs the duration of analgesia, but also results in a greater decrease in blood pressure. Despite this effect on blood pressure, there was no difference in ephedrine use.

A Delivery Room Approach to the Meconium Aspiration Syndrome (MAS) Immediate Intubation, Endotracheal Suction, and Oxygen Administration Can Reduce Morbidity and Mortality

From the Department of Pediatrics, Obstetrics and Gynecology and Anesthesiology of the University of Pennsylvania School of Medicine and The Children’s Hospital of Philadelphia, Philadelphia, Pa. 19104. Correspondence to: William W. Fox, M.D., The Children’s Hospital of Philadelphia, Civic Center Boulevard, Philadelphia, PA 19104. SIGNIFICANT CAUSE of neonatal morbidity and mortality, the meconium aspiration syndrome (MAS) is the result of perinatal stress induced by reflex evacuation of meconium, followed by aspiration of the meconium-containing amniotic fluid. Preventive and therapeutic approaches to the syndrome inclu~:e: fetal monitoring of the high risk pregnancy to detect possible asphyxia early’; appropriate resuscitation in the delivery room; and intensive neonatal care implemented by chest physiotherapy, positive end-expiratory pressure’ and mechanical ventilation. 3

Amphetamine Abuse and Obstetrical Anesthesia

To the Editor: The report by Samuels, Maze, and Albright (Cardiac arrest during cesarean section in a chronic amphetamine abuser. Anesth Analg 55:528-530, 1979) suggests that under certain conditions amphetamine users may have marked adverse reactions to anesthesia. Our recent experience with an amphetamine user who developed pulmonary edema after cesarean section supports this concept. The patient was 25 years old and presented at 32 weeks gestation in active labor. She gave a history of chronic amphetamine abuse and stated that she had taken amphetamines 8 hours before admission. She had no history of heart or lung disease and denied taking other drugs. Her weight was approximately 70 kg. At the time of admission blood pressure was 100/60 mm Hg; pulse 100 beats per minute; temperature 39.1 c (oral). Fetal heart rate wits 80 to 100 beats per minute. A fetal scalp blood specimen had a pH of 6.7. Emergency cesarean section for fetal distress was scheduled. After preoxygenation, left uterine displacement, atropine (0.5 mg IV), and d-tubocurarine (3 mg IV), anesthesia was induced with thiopental (250 mg IV) following which succinylcholine (100 mg IV) was given. Cricoid pressure was applied and the trachea was intubated. There was no evidence of gastric contents in the airway. Breath sounds were heard bilaterally and remained normal throughout the operation. Anesthesia was maintained with nitrous oxide (50%), halothane (0.5%), and a continuous infusion of succinylcholine. Diazepam (10 mg IV) and morphine (10 mg IV) were given after the delivery. Five minutes after induction, a 2.1-kg boy was delivered. The infant had Apgar scores of 1 and 3 at 1 and 5 minutes, respectively, and subsequently died on the 4th postpartum day from respiratory arrest and intracranial bleeding. Ampicillin and gentamycin were given intravenously to the mother immediately after delivery. The anesthetic was complicated by hypotension (systolic blood pressure 70 mm Hg, tachycardia (pulse 110 beats/min), pronounced peripheral vasoconstriction, and oliguria. These were treated with plasma protein fraction (500 ml), normal saline (600 mi), and lactated Ringer’s solution (700 ml) for a total volume of 1500 ml during the 1 k h o u r operation. There was minimal blood loss (estimated at 400 ml) and the placenta appeared to be vasoconstricted. Despite fluid therapy, blood pressure remained low (70 to 90 mm Hg systolic) and pulse rate elevated (110 beats/min) throughout the operation. Urine output during surgery was 40 ml. The patient was responsive and breathing spontaneously at the end of the op, eration and the trachea was extubated in the operating room. However, during transfer to the recovery room, the patient became tachypneic (36 breaths/min); rales and wheezes were now heard bilaterally. A central venous pressure (CVP) catheter was inserted; the CVP was 16 cm H20. Minute ventilation was 10.8 L, vital capacity 1 L. Blood gas tensions while breathing 60% 0 2 by mask (actual FIO, was probably lower) were Pa*., 83 mm Hg, Pace, 42.9 mm Hg; pH was 7.27, and base excess 6.8 meq/L. Chest x-ray was compatible with pulmonary edema. Despite furosemide (10 mg), urine output of 1 L, and supplemental oxygen, the patient’s oxygenation deteriorated over the next 5 hours with an Fie, 0.60, the Pao, was 60 mm Hg, I‘aco, 32.7 mm Hg, pH 7.34, and base excess -5.0 meq/L. The trachea was reintubated. Over the next 5 hours, with further diuresis, positive pressure ventilation, and PEEP (6 cm H20) oxygenation improved, the CVP decreased to 12 cm H 2 0 , and the endotracheal tube was removed. The rest of her hospital course was uneventful. The severity, but rapid resolution of her pulmonary edema makes pneumonia, aspiration, pulmonary embolism, and amniotic fluid embolism unlikely causes of our patient’s respiratory failure. Sepsis may cause respiratory failure, but cultures of blood, sputum and amniotic fluid were unremarkable and the placenta showed no histologic evidence of inflammation or infection. Her elevated temperature resolved promptly after delivery. Allergic reactions to anesthetic agents or antibiotics were unlikely; she had no hives, rash, or laryngospasm; rales were more prominent than wheezing. The 1500 ml of intraoperative fluids, by itself, would be unlikely to cause pulmonary edema in an otherwise healthy patient especially one with signs of volume depletion (hypotension, tachycardia, low urine output). Thus this patient’s postanesthetic pulmonary edema is unexplained, except for the possible association with chronic amphetamine use (a screening test on urine, obtained after delivery, was positive for amphetamine). Although chronic amphetamine use depletes catecholamines, acute administration may cause vasoconstriction suggesting the presence of a reduced vascular capacity coupled with inadequate cardiac reserve in our patient. Although we cannot substantiate that amphetamine use was the causative factor in our patient’s pul-

The Zavanelli maneuver does not preclude regional anesthesia

S houlder dystocia occurs in 0.23%-2.09% of all vaginal deliveries and is a true obsketrical emergency (1). Risk factors include maternal obesity, diabetes mellitus, postdates pregnancy, fetal macrosomia, prolonged second stage of labor, oxytocin induction, and instrumental extraction (2,3). There are several maneuvers for the management of shoulder dystocia, which occurs during the second stage of labor or delivery. These include application of suprapubic pressure posteriorly (Mazzanti maneuver), flexing the legs onto the abdomen (McRoberts maneuver), rotational maneuver of the shoulder girdle (Wood’s screw rotational maneuver) (4,5), and cephalic replacement (Zavanelli maneuver) (6,7). Effective regional anesthesia will facilitate these maneuvers and enhance maternal cooperation. The Zavanelli maneuver involves manually replacing the feral head into the relaxed uterus followed by cesarean section. Recommendations to provide uterine relaxation include either deep general anesthesia or tocolysis with intravenous (IV) or subcutaneous terbutaline (1,8,9). We present a case in which the Zavanelli maneuver was performed under epidural anesthesia with uterine relaxation provided by amyl nitrite inhalation.

Patient Variables and the Subarachnoid Spread of Hyperbaric Bupivacaine in the Term Patient

To determine if age, height, weight, body mass index, or vertebral column length significantly influence the distribution of sensory analgesia or anesthesia after subarachnoid injection of hyperbaric bupivacaine, 52 women presenting for cesarean section were studied. All received 15 mg hyperbaric bupivacaine via subarachnoid injection at L-2 or L-3. Fifteen minutes after injection, while the women lay supine on a horizontal operating table, the maximum cephalad extent of sensory analgesia (loss of sensation of sharpness to pin prick) and anesthesia (loss of sensation of light touch) was determined. Age (20-42 yr), height (146.9-174.0 cm), weight (55.5-136.4 kg), body mass index (19.2-50.0 kg/m2), and vertebral column length (49.6-67.0 cm) did not correlate with the spread of sensory blockade. In conclusion, in parturients of age, height, weight, body mass index, and vertebral column length within the aforementioned ranges, it is not necessary to vary the dose of injected hyperbaric bupivacaine with changes in any of the patient variables studied.

Bupivacaine 0.01 % and/or Epinephrine 0.5 ??g/ml Improve Epidural Fentanyl Analgesia after Cesarean Section

BACKGROUND The authors studied the addition of bupivacaine and epinephrine, separately and together, to epidural fentanyl to determine whether this improved postcesarean analgesia and reduced the incidence of side effects. METHODS After elective cesarean section, 100 parturient patients who received fentanyl (3 microg/ml) epidurally for 48 h were allocated randomly in a double-blinded manner to four groups to receive, in addition to the study solution, 0.01% bupivacaine, 0.5 microg/ml epinephrine, both, or neither. A neurologic assessment of breast-fed neonates was made at 2 and 48 h of life. Plasma fentanyl concentrations were determined in a subset of patients at intervals after treatment. RESULTS Patients receiving fentanyl alone made more attempts at patient-controlled analgesia (P < 0.01), required a greater total dose of fentanyl (P < 0.01), reported more pain (P < 0.003) and less satisfaction (P < 0.003), and had more nausea and urinary retention (P < 0.05) than all other groups. Patients who received bupivacaine with or without epinephrine had better overall satisfaction scores than those who did not receive bupivacaine (P < 0.001), and they required less fentanyl (P < 0.02) than patients who received fentanyl with only epinephrine. Motor blockade or orthostatic hypotension did not develop in any patient, and all patients could ambulate without difficulty. Neurobehavioral scores, which were similar among all neonates, were within the normal range. Plasma concentrations of fentanyl increased after epinephrine-containing solutions were discontinued. CONCLUSIONS During the conditions of this study, the addition of epinephrine and bupivacaine to a 3-microg/ml epidural fentanyl solution for postcesarean section pain relief provided superior analgesia compared with fentanyl alone or fentanyl with epinephrine. Whether increasing the concentration of fentanyl alone might improve the efficacy of fentanyl remains unclear.

Blood Loss During First Trimester Termination of Pregnancy: Comparison of Two Anaesthetic Techniques

We have compared the effects of two anaesthetic techniques on blood loss during suction termination of pregnancy. Forty-eight ASA grade I-II patients were allocated randomly to one of two groups: group 1 received propofol induction followed by a standard propofol infusion; group 2 received propofol induction followed by maintenance with 1% isoflurane. Both groups received bolus doses of either propofol (group 1) or isoflurane (group 2) if anaesthesia was too light. All patients were given fentanyl 1 micrograms kg-1 on induction. The products of conception were evacuated into a closed suction bottle. The products were diluted with 500 ml of heparinized saline, filtered and left for 20 min. Estimation of blood loss was performed by atomic absorption spectrometry. Mean blood losses were 40.4 ml for the isoflurane group and 18.8 ml for the propofol group. This difference was statistically significant (P = 0.0011), although actual volumes of blood loss were small and not clinically significant.