Bupesh Kaul

Epidural labor analgesia and neonatal sepsis evaluation rate: a quality improvement study.

Labor epidural analgesia (LEA) is allegedly associated with maternal fever and an increase in the newborn sepsis work-up (SWU) rate. In this study, we evaluated whether LEA causes an increase in the SWU rate compared with a Control group given parenteral narcotics for labor pain. Maternal and neonatal data were collected prospectively for a continuous quality improvement database. Odds ratios were calculated by using multiple logistic regression for various triggers for SWU in the neonate. Of the 1177 primiparous women and their neonates studied, 922 women received LEA and 255 women received parenteral analgesics. A small but statistically significant increase in maternal and neonatal temperatures occurred in parturients receiving LEA. The SWU rates were 7.5% in the LEA group and 9.4% in the Controls (not significant). Triggers identified for SWU were birth weight (odds ratio = 116, P = 0.000), gestational age (odds ratio = 86.6, P = 0.000), meconium aspiration and respiratory distress requiring intubation (odds ratio = 8.6, P = 0.000), hypothermia at birth (odds ratio = 7.1, P = 0.001), maternal Group B &bgr;-hemolytic streptococcal colonization (odds ratio = 6, P = 0.000), and preeclampsia or hypertension (odds ratio = 3.5, P = 0.03). There was no association between LEA and SWU.

Chorioamnionitis, not epidural analgesia, is associated with maternal fever during labour

PurposeMaternal fever is associated with chorioamnionitis and has been linked to labour epidural analgesia (LEA). The purpose of this study was to determine possible associations between LEA and chorioamnionitis, maternal fever, operative delivery rate, and neonatal outcome.MethodsData from 14,073 patients were entered into a database over a two-year period. From this database, 62 nulliparous parturients with clinical chorioamnionitis (amnionitis), but without LEA were identified (Group I). Two other groups who received LEA were matched for parity and gestation: Group II — LEA with concomitant amnionitis (n = 50) and, Group III — LEA without concomitant amnionitis (n=201). The diagnosis of chorioamnionitis was confirmed by histologic examination. Results are expressed as mean ± SD and analyzed atP < 0.05 using ANOVA or Chi-square.ResultsNo differences were noted among the groups in the operative delivery rate or Apgar scores at five minutes. The percentage of patients with maternal fever during labour (38.0°C) with amnionitis was significantly less in Group III compared to the other groups (100% in both Groups I and IIvs 1.0% in Group III;P=0.000). Likewise, Group III had a lower percentage of neonates with Apgar scores < 7 at one minute (35.5% in Group I, 20.0% in Group II, 17.4% in Group III;P=0.010). The percentage of histologic chorioamnionitis was significantly higher in both amnionitis groups compared to Group III (67.7% in Group I, 56.0% in Group II, 4.0% in Group III;P=0.000).ConclusionLEA without chorioamnionitis is not associated with maternal fever (38.0°C), increased operative delivery rates or low Apgar scores.RésuméObjectifLa fièvre puerpérale est associée à la chorioamnionite et a été reliée à l’analgésie épidurale pendant le travail (AET). L’objectif de la présente étude était de déterminer les associations possibles entre AET et, chorioamnionite, fièvre puerpérale, taux de césarienne et évolution néonatale.MéthodePendant deux ans, on a inscrit dans une base de données les informations concernant 14 073 patientes. À partir de cette base de données, on a repéré 62 parturientes nullipares qui présentaient une chorioamnionite clinique, sans AET (groupe I). Deux autres groupes de femmes qui ont reçu une AET ont été appariés pour la parité et la gestation: le groupe II qui comportait une AET et une amnionite concomitante (n = 50), et le groupe III avec AET mais sans amnionite concomitante (n = 201). Le diagnostic de chorioamnionite a été confirmé par un examen histologique. Les résultats ont été exprimés par la moyenne ± l’écart type et analysés à P < 0,05 en utilisant une analyse de variance ou la méthode du Chi2.RésultatsAucune différence intergroupe n’est apparue quant au taux de césarienne ou à l’indice d’Apgar à cinq minutes. Le pourcentage de patientes atteintes de fièvre puerpérale pendant le travail (38,0°C) et d’amnionite a été significativement moindre dans le groupe III comparé aux deux autres groupes (100% dans les groupes I et II vs 1,0 % dans le groupe III; P = 0,000). Aussi, le groupe III a présenté un pourcentage plus faible de nouveaunés avec un indice d’Apgar < 7 à une minute (35,5 % dans le groupe I, 20,0 % dans le groupe II, 17,4 % dans le groupe III; P = 0,010). Le pourcentage de chorioamnionite histologique a été signifeativement plus élevé dans les deux groupes avec amnionite comparés au groupe III (67,7% dans le groupe 1, 56,0 % dans le groupe II, 4,0 % dans le groupe III; P = 0,000).ConclusionL’AET sans chorioamnionite n’est pas associée à la fièvre puerpérale (38,0°C), à un taux élevé de césarienne ou à un faible indice d’Apgar.

Transdermal scopolamine patch in addition to ondansetron for postoperative nausea and vomiting prophylaxis in patients undergoing ambulatory cosmetic surgery

STUDY OBJECTIVE To determine the efficacy of transdermal scopolamine in addition to ondansetron in decreasing the incidence of postoperative nausea and vomiting (PONV). DESIGN Randomized controlled trial. SETTING Academic hospital. PATIENTS 126 ASA physical status I and II patients undergoing outpatient plastic surgery with three or more risk factors for PONV. INTERVENTIONS Patients were randomly assigned to one of two groups to receive (Group 1) a transdermal scopolamine (TDS) patch or (Group 2), a placebo patch two hours before surgery. MEASUREMENTS Occurrence of vomiting, severity of nausea using a visual analog scale (VAS), rescue medication, pain intensity and pain medications, and side effects were recorded every hour until discharge from hospital, then every 4 hours thereafter for a total of 24 hours. MAIN RESULTS A statistically significant reduction in postoperative nausea between 8 and 24 hours in patients receiving TDS was noted. CONCLUSIONS Transdermal scopolamine in addition to ondansetron benefits patients at high risk for PONV undergoing outpatient plastic surgery for up to 20 hours after surgery.

Amniotic fluid embolism with second trimester pregnancy termination: a case report.

PurposeDescribe the diagnosis, clinical features, pathophysiology, treatment and anesthetic management of amniotic fluid embolism (AFE) in a patient undergoing second trimester pregnancy termination.Clinical featuresA 30-yr-old gravida 2, para 1, woman was admitted for a dilatation and evacuation procedure for underlying intra-uterine fetal demise in her second trimester of pregnancy. Hypotension, shock, respiratory arrest, pulseless electrical activity, hemorrhage, disseminated intravascular coagulopathy, requiring cardiopulmonary resuscitation and blood transfusion complicated her intraoperative care. AFE was considered the most likely cause of this intraoperative event.ConclusionsIt is now recognized that the pathophysiological features of AFE are similar to a type-I hypersensitivity reaction ranging from mild systemic reaction to anaphylaxis and shock. AFE has a high maternal and fetal morbidity and mortality rate, requiring prompt recognition and treatment. In patients with cardiovascular instability, the treatment of AFE is similar to anaphylaxis requiring aggressive fluid hydration, cardiopulmonary resuscitation, administration of blood products and the use of vasopressors.RésuméObjectifDécrire le diagnostic, les éléments cliniques, la physiopathologie, le traitement et les mesures anesthésiques entourant une embolie amniotique (EA) chez une patiente qui a subi une interruption de grossesse au deuxième trimestre.Éléments cliniquesUne femme de 30 ans, G2 P1, a été admise pour subir une dilatation et une évacuation pour mort fœtale pendant le deuxième trimestre de la grossesse. Hypotension, choc, arrêt respiratoire, dissociation électromécanique, hémorragie, coagulopathie intravasculaire disséminée nécessitant une réanimation cardio-pulmonaire et une transfusion sanguine ont compliqué les soins peropératoires. L’EA a été considérée comme la cause la plus probable de cet événement peropératoire.ConclusionsOn sait maintenant que les caractéristiques physiopathologiques d’une EA sont similaires à une réaction d’hypersensibilité de type I allant d’une réaction bénigne généralisée à l’anaphylaxie et au choc. L’EA présente un taux élevé de morbidité et de mortalité maternelles et fœtales qui nécessitent une identification et un traitement rapides. En cas d’instabilité cardiovasculaire, le traitement de l’EA est semblable à celui de l’anaphylaxie et requiert une hydratation liquide importante, une réanimation cardio-pulmonaire, l’administration de dérivés sanguins et l’usage de vasopresseurs.

Accidental spinal analgesia in the presence of a lumboperitoneal shunt in an obese parturient receiving enoxaparin therapy.

IMPLICATIONS A single shot spinal anesthetic is not practical in a patient with a lumboperitoneal shunt. Neuraxial block and a blood patch (if necessary) may be performed in a patient on enoxaparin therapy if current guidelines for managing patients on anticoagulant therapy are followed.

Piriformis syndrome in a patient after cesarean section under spinal anesthesia

Objectives The diagnosis, pathogenesis, and treatment of piriformis syndrome as a cause of persistent buttock and hip pain after spinal anesthesia are presented in this case report. Case Report A 29-year-old woman presented 5 days after cesarean delivery with sudden onset of pain in the left buttock and left hip radiating to the posterior knee with fever. She was subsequently diagnosed with piriformis syndrome. Conclusions Back pain with radiation into the buttocks after spinal anesthesia is frequently attributed to the spinal procedure itself. However, prolonged sitting and weight bearing in the upright position after cesarean delivery can cause sciatic nerve compression at the sacroiliac joint with concomitant irritation, inflammation, and spasm of the piriformis muscle. Piriformis syndrome is frequently underdiagnosed in the obstetric population. Because the diagnosis of piriformis syndrome is based mainly on clinical signs and symptoms, the clinician must have a high index of suspicion.

Improved bowel function after gynecological surgery with epidural bupivacaine-fentanyl than bupivacaine-morphine infusion.

Purpose: To compare postoperative gastrointestinal recovery between continuous epidural bupivacaine-fentanyl and bupivacaine-morphine.Methods: In a blinded, randomized, prospective trial, 60 women undergoing surgery for gynecologic cancer were studied. Anesthesia was provided by a combined general/epidural (L2–3 catheter) technique without epidural opioids. Postoperative epidural analgesia was by continuous infusion of bupivacaine 0.1% with either morphine 0.05 mg·ml−1 (BM) or fentanyl 5 µg·ml−1 (BF). Visual Analogue Scale (VAS) scores for pain at rest and during movement, and the return of bowel function were collected for three days and the duration of hospitalization were noted.Results: On POD-1, 18.5% of patients in the BM group had emesis compared with none in the BF group (P=0.038) and fewer patients in the BM group tolerated clear oral fluids (11.1% BM vs 40.6% BF,P=0.025). These differences became insignificant on POD-2 and 3. Median pain scores were comparable at rest and ranged from 10–20 in the BM group vs 0–20 in the BF group over the three days. Similarly, median pain scores with movement respectively ranged from 20–25 and 20–30 in the BF and BM groups. The mean duration of hospitalization was longer in the BM group (5.7±2.4) vs BF (4.5±1.2 days),P=0.017.Conclusion: Epidural BM and BF provided equally effective postoperative analgesia at rest and during movement. Compared with BM, epidural BF is associated with less emesis and an increased ability to tolerate oral fluids on POD-I and an overall shorter hospital stay.RésuméObjectif: Comparer la récupération gastro-intestinale postopératoire à la suite d’une perfusion péridurale continue avec bupivacaïne et, fentanyl ou morphine.Méthode: L’étude à l’insu, randomisée et prospective a porté sur 60 femmes qui ont subi l’opération d’un cancer gynécologique. Une technique générale/péridurale combinée (cathéter dans l’espace L2–3) sans opioïdes périduraux a permis l’anesthésie. L’analgésie péridurale postopératoire comprenait une perfusion continue de bupivacaïne à 0,1 % avec, soit 0,05mg·ml−1 de morphine (BM), soit 5µg·ml−1 de fentanyl (BF). On a enregistré pendant 3 jrs les scores de douleur au repos et pendant le mouvement à l’échelle visuelle analogique (EVA), et le retour de la fonction intestinale. La durée de l’hospitalisation a été notée.Résultats: Au jour I postopératoire, 18,5 % des patientes du groupe BM avaient des vomissements mais aucune du groupe BF (P=0,038) et peu de patientes du groupe BM ont toléré les liquides oraux clairs (11,1 % BM vs 40,6 % BF,P=0,025). Ces différences n’étaient plus significatives aux jours 2 et 3. Les scores moyens de douleur ont été comparables au repos et allaient de 10–20 pour le groupe BMvs 0–20 pour le groupe BF au cours des trois jours. De même, les scores moyens de douleur au mouvement se retrouvaient respectivement de 20–25 et de 20–30 pour les groupes BF et BM. La durée moyenne d’hospitalisation a été plus longue dans le groupe BM (5,7±2,4) vs le groupe BF (4,5±1,2 jours),P=0,017.Conclusion: L’analgésie péridurale BM et l’analgésie BF ont fourni un soulagement équivalent de la douleur postopératoire au repos et lors de mouvements. L’analgésie avec BF, comparée à l’analgésie avec BM, est associée à moins de vomissement et à une capacité accrue de tolérance aux liquides oraux le premier jour postopératoire ainsi qu’à un séjour hospitalier plus court.

Thrombophilia, Preeclampsia, and Fetal Demise: A Case Report

A patient with thrombophilia, preeclampsia, and fetal demise who was taking low molecular weight heparin, was managed with epidural analgesia for labor and delivery of the fetus. The anesthetic considerations and medical concerns in such patients are discussed.