Bruno Antonio Zanfini

Remifentanil for cesarean section under general anesthesia: effects on maternal stress hormone secretion and neonatal well-being: a randomized trial

BACKGROUND Remifentanil may attenuate maternal hemodynamic response during cesarean section under general anesthesia, but could cause transient but significant neonatal depression. We investigated the effect of low-dose remifentanil on maternal neuroendocrine response and fetal wellbeing. METHODS Forty-two ASA I-II parturients undergoing cesarean section at term under general anesthesia were randomized to receive either fentanyl after delivery (n=21, group C) or remifentanil bolus 0.5 microg/kg before induction followed by a continuous infusion at 0.15 microg x kg(-1)min(-1) until peritoneal incision, then restarted after delivery (n=21, group R). Maternal heart rate and blood pressure, and epinephrine, norepinephrine, adrenocorticotropic hormone (ACTH), and growth hormone levels were measured at baseline, uterine incision, and the end of surgery. Remifentanil was measured in maternal and umbilical arterial and venous blood. One- and 5-minute Apgar scores and umbilical arterial and venous pH were recorded. RESULTS ACTH was significantly higher in group C at uterine incision (P<0.01). No significant differences were observed in hemodynamics, catecholamines or growth hormone. Apgar scores at 1 (P<0.05) and 5 min (P<0.01) were significantly higher in group C. Mean umbilical pH values were within normal range but significantly higher in group C. Three neonates in group R required intubation but recovered at 5 min without naloxone. Mean+/-SD maternal remifentanil concentration was 1.67+/-1.04 ng/mL. CONCLUSIONS Remifentanil administration before peritoneal incision partially reduced the hormonal stress response. Maternal benefits must be weighed against transitory but significant neonatal respiratory depression. Neonatal resuscitation facilities are mandatory when remifentanil is used.

Latex Sensitization: A Special Risk for the Obstetric Population?

Background:Previous studies have reported a greater frequency of sensitization to latex in the female population and a higher incidence of anaphylactic reactions to latex during cesarean section. In this study, the authors investigated the prevalence of latex sensitization in obstetric patients compared with nonpregnant subjects. Methods:Two hundred ninety-four healthy pregnant women who were at term with a singleton fetus and scheduled for caesarean section (group A) were compared with 294 healthy nulliparous women with childbirth potential undergoing gynecologic surgery (group B). Before surgery, patients completed a questionnaire, and venous blood samples were collected to measure specific immunoglobulin E serum concentrations with a fluorescent enzyme immunoassay test. Skin-prick tests were performed if adverse reactions occurred during surgery. Latex allergy was diagnosed on the basis of immunoglobulin E results and/or positive skin-prick tests. Results:The prevalence of latex sensitization was higher in group A than in group B (15/294, 5.1% vs. 5/294, 1.7%; P < 0.05). A significant difference in specific immunoglobulin E serum concentration was noted between pregnant and nonpregnant patients who had a positive fluorescent enzyme immunoassay test (median serum concentration: 1.93 kilounits/l; interquartile range = 2.28 vs. 0.78 kilounits/l; interquartile range = 1.07; P less than 0.05). Two patients in group A experienced an anaphylactic reaction to latex. Statistical analysis disclosed no association between latex sensitization and accepted risk factor for latex allergy. Conclusions:The authors report a higher prevalence of latex sensitization in the obstetric population than in nonpregnant subjects undergoing gynecologic surgery.

Does Huntington's disease enhance cephalad spread during neuraxial anesthesia for cesarean section?

To the Editor: Huntingtons disease has several implications for anesthesiologists. Cognitive dysfunction and dyskinesia may complicate both general and neuraxial anesthesia. The management of two consecutive Cesarean sections performed in the same Huntingtons disease patient is presented. At the first cesarean section, the patient was 32 years old, 166 cm, with a body mass index of 23.4 kg/m2. She presented with minimal signs of involuntary movement; the diagnosis of Huntingtons disease was confirmed by family history and genetic counseling. She underwent an urgent Cesarean section for suspected placental abruption and preeclampsia. With the patient placed in sitting position, a single-shot spinal anesthesia with a 25-gauge (G) Whitacre needle was performed at the L3-L4 interspace. Hyperbaric bupivacaine 0.5% 12 mg plus sufentanil 5 μg were administered intrathecally. Sensory block reached T5 in 10 minutes and reverted to T10 after 130 minutes. Four years later, during elective Cesarean section, the patient showed clinical deterioration, mild dementia, and increased involuntary movements without modification of body habitus. Combined spinal-epidural anesthesia was performed to ensure adequate postoperative analgesia. The patient was placed in sitting position; the epidural space was entered at the L3-L4 level with an 18-G Tuohy needle (lossof-resistance technique). Needle-through-needle spinal anesthesia was performed with hyperbaric bupivacaine 0.5% 7 mg plus sufentanil 5 μg. An epidural catheter was then inserted. Unexpectedly, after 15 minutes the sensory block reached C6-C7, resulting in severe hypotension that was treated with fluids and ephedrine intravenously (IV). Delivery was completed uneventfully. After 150 minutes, the analgesic block reverted to T10 and morphine 2.5 mg was administered epidurally. A normal spread of spinal anesthetic has been reported in a few nonpregnant Huntingtons disease patients undergoing spinal anesthesia [1]. In pregnant women, anatomical changes are responsible for the cephalad spread of spinal anesthetics [2,3]. It is controversial whether the spread of

Successful use of spinal anesthesia for an urgent cesarean section in a parturient with a severe Klippel-Trénaunay syndrome

mation with an incidence of 1 out of 27,500 live births described in 1900 including a triad of port-wine stain/capillary vascular malformation, venous malformation/varicose veins, soft tissue, and bony hypertrophy in affected limbs [1]. Although a combined spinal-epidural technique for an elective cesarean section and an epidural analgesia for vaginal delivery have been already presented [2,3], this is the first report that describes spinal anesthesia for an urgent cesarean section in a patient with KTS. A 23-year-old woman (gravidity: 1, parity: 0) was referred to our Anesthesia Preadmission Clinic at 37 weeks of gestation because of KTS complicating her pregnancy. She weighed 115 kg and was 170 cm in height (body mass index 39.8 kg/m). She had been diagnosed with KTS at the age of 16 and received several surgical treatments for her right foot varicosities and opioid therapy till the beginning of gestation because of pain in the right leg. She did not have a history of thrombosis or hemorrhage. On hospital admission at 37 weeks of gestation for planned delivery, physical examination showed prominent hypertrophy and multiple varicosities of the right leg (Fig. 1). The circumferences of the thigh, calf, ankle, and knee were 12, 15, 11, and 10 cm, respectively, larger than the left side. Laboratory studies revealed a normal coagulation profile and hemoglobin (Hb) count of 8.5 g/dl. She was scheduled for a magnetic resonance imaging (MRI) scan to determine the existence of arterio-venous malformations (AVM) or hemangiomas in the pelvis, birth canal, spinal cord, bronchial tube, and brain before delivery, but she had not yet undergone MRI. She was admitted to our delivery unit at 38 weeks of gestation for an urgent cesarean section due to abnormal cardiotocography (type 2 urgency according to Lucas’ classification). On admission, she was anxious and had breakfast two hours before. On physical examination, her airway revealed a Mallampati Class III and her back had normal anatomy with clearly palpable landmarks with no evidence of port-wine stains. Ultrasound revealed no signs of detectable vascular abnormalities. She refused any attempt Letter to the Editor

Anesthetic management of urgent cesarean delivery in a parturient with acute malaria infection: a case report

Malaria is associated with high rates of morbidity and mortality worldwide, particularly in Africa, Southeast Asia and South America. Nonetheless, several cases of malaria have been reported in Western countries involving travelers from endemic areas, though very few involve pregnant women. In this article, we report a case of a young woman born in Sierra Leone who had been living in Italy for two years. She was admitted to our hospital with malaise; worsening of her condition led to Plasmodium falciparum infection diagnosis early during her hospital stay, as well as an urgent cesarean delivery. We briefly discuss the features of malaria in pregnancy, the difficulties associated with early diagnosis, and the possible fetal and maternal implications, and also consider how the disease may affect anesthetic management.

Low-dose S-ketamine for postoperative pain in cesarean section with spinal anesthesia: 11AP2-8

Anesthesia and Intensive Care, Catholic University of the Sacred Heart, Rome, Italy Background and Goal of the study: Numerous studies showed the antihyperalgesic effects of small-dose ketamine on postoperative pain in patients under general anaesthesia. We investigated the analgesic efficacy and safety of low-dose S-ketamine infusion in patients undergoing cesarean section with spinal anesthesia. Material and Methods: Twenty-eight ASA I-II women, 18–40 years old, with uncomplicated pregnancies at term, scheduled for elective repeated cesarean section, were randomized to receive S-ketamine or placebo. In both groups subarachnoid anesthesia was performed with 0.5 % hyperbaric bupivacaine (8–10 mg) plus sufentanyl 5 g. Study group received 0.5 mg/kg i.m. S-ketamine bolus 10 min after birth, followed by 2 g/kg/min continuous i.v. infusion for 12 h. Control group received normal saline in the same way. At the end of surgery a 24 h PCA i.v. morphine analgesia was started in all patients. Time to first request of analgesia, total morphine consumption, VAS, Ramsay Sedation Scores (RSS) and side effects were collected at 1, 4, 8, 12, 24 h. RMand M-ANOVA and Student’s T-tests were used for statistical analysis. Results and Discussion: Patients characteristics (mean SD) were: age 33.9 yrs 4.3, weight 74.5 kg 10.2, height 157 cm 4.6. Mean time to first morphine request was 382 min 275 for the S-ketamine group, versus 220 min 102 for the control group (P 0.022). Cumulative morphine consumption in S-ketamine and control group was respectively 9.86 mg 6.18 and 15 mg 5.43 at 12 h (P 0.014) and 21.71 mg 10.2 and 32.72 mg 6.53 at 24 h (P 0.026). Side effects observed in S-ketamine group only were: dizziness and drowsiness in 100%, diplopia in 43% (P 0.004) and nystagmus in 36% (P 0.012) of patients. All side effects were mild and transient. There were no significant differences in VAS and RSS. Conclusions: Low-dose S-ketamine, administered by i.m. bolus and continuous i.v. infusion, reduced morphine consumption and prolonged postoperative analgesia after cesarean section with spinal anesthesia. Only minor side effects were detected. Low-dose S-ketamine has shown to be beneficial in awake surgical patients with neuraxial block.