C. Moore

Comparing the efficacy of prophylactic metoclopramide, ondansetron, and placebo in cesarean section patients given epidural anesthesia

STUDY OBJECTIVE To compare the relative efficacy of prophylactic metoclopramide, ondansetron, and placebo in nonemergent cesarean section patients given epidural anesthesia intraoperatively and for the first 24-hour period after delivery. DESIGN Randomized, double blind, placebo-controlled study. SETTING Inpatient obstetric unit at a university hospital center. PATIENTS 164 nonemergent cesarean section patients given epidural anesthesia. INTERVENTION At time of umbilical cord clamp, patients received intravenously (IV) either 4 mg ondansetron (Group O) or 10 mg metoclopramide (Group M) or 10 mL normal saline (Group P). MEASUREMENTS AND MAIN RESULTS Episodes and severity of nausea and vomiting, rescue antiemetic requirement, patient satisfaction, and side effects were recorded. The frequency of intraoperative nausea were 24%, 43%, and 57% for Group O, Group M, and Group P, respectively (p < 0.03). The frequency of nausea for the 24-hour study period were 26%, 51% and 71% for Groups O, M, and P respectively (p < 0.03). The frequency of intraoperative and postoperative vomiting were similar between Group O and Group M, but significantly higher in Group P (p < 0.05). Overall patient satisfaction was highest in Group O compared with Groups P and M (p < 0.05). Maximum analog sedation score was higher in Group M compared to Groups O and P (p < 0.05). CONCLUSIONS In cesarean section patients given epidural anesthesia, prophylactic ondansetron, 4 mg IV, is more efficacious and has a higher patient satisfaction than that with metoclopramide, 10 mg IV, or placebo in preventing nausea and achieving complete responses during intraoperative period and the first 24-hour postdelivery period. However, there is no difference between ondansetron and metoclopramide in reducing frequency of vomiting. Prophylactic ondansetron 4 mg IV is more effective in preventing nausea than vomiting.

Intraoperative antiemetic efficacy of prophylactic ondansetron versus droperidol for cesarean section patients under epidural anesthesia

The efficacy of ondansetron and droperidol were evaluated for prophylactic treatment of nausea and vomiting in cesarean section patients under epidural anesthesia.Forty-eight ASA physical status I-II parturients requiring nonemergent cesarean section gave their consent and were randomly assigned into one of three treatment groups (n = 16 each) according to a double-blind, placebo-controlled protocol. When the fetal umbilical cord was clamped, patients received intravenously 8 mg of ondansetron or 0.625 mg of droperidol or saline depending on their treatment group. Ninety-four percent of the ondansetron group, 88% of the droperidol group, and 56% of the placebo group were emesis free. Sixty-nine percent of the ondansetron group, 75% of the droperidol group, and 31% of the placebo group were nausea free. This study showed a significantly lower incidence of nausea and vomiting and a tendency toward less severe emetic symptoms in the ondansetron and the droperidol groups than in the placebo group, but the ondansetron group was not statistically different from the droperidol group. This study is the first to report the antiemetic efficacy of prophylactic ondansetron in cesarean section patients or in patients under epidural anesthesia for abdominal surgery. Both prophylactic ondansetron and droperidol were similarly effective, and significantly better than placebo, in reducing the incidence and severity of intraoperative emetic symptoms in cesarean section patients under epidural anesthesia. (Anesth Analg 1996;83:982-6)

Antisense Oligodeoxynucleotides to the Kappa1 Receptor Enhance Δ9-THC–Induced Antinociceptive Tolerance

Delta-9-tetrahydrocannabinol produces potent antinociceptive effects in mice and rats. Evidence exists for an interaction between the cannabinoids and the kappa receptor subtype, kappa1, in the production of antinociception. Data indicate that delta9-THC induces the release of endogenous dynorphins, the ligand(s) for the kappa receptor. It has been demonstrated that antisense oligodeoxynucleotides directed against the kappa1 receptor attenuate the antinociceptive effects of delta9-THC. The exact mechanism for the expression of cannabinoid tolerance is unknown. Bidirectional cross-tolerance between the kappa opioids and delta9-THC implies that a common mechanism may be responsible for tolerance expression. We tested the hypothesis that the kappa1 receptor is involved in tolerance to delta9-THC. Antisense to the kappa1 receptor has been shown to downregulate the kappa receptor. We observed a significant increase in the ED50 for delta9-THC in antisense-, but not mismatch-treated mice, indicating an increase in tolerance to delta9-THC. Such data indicate that a decrease in kappa receptor number may accompany tolerance to delta9-THC.

Incidence of postdural puncture headache and backache, and success rate of dural puncture: comparison of two spinal needle designs.

Objectives The goal of this randomized study was to compare the incidence of postdural puncture headache (PDPH) and postdural puncture backache (PDPB), and the success rate between two small-gauge spinal needle designs used in women undergoing subarachnoid block anesthesia. Methods After Institutional Review Board approval, 215 patients presenting for tubal ligation were randomly assigned to have 26-gauge Atraucan (AT group) or 25-gauge Whitacre (WH group) spinal needles used in their spinal anesthesia. The number of attempts to successful cerebrospinal fluid return and the success rate of the spinal blockade were documented. Postoperatively, an investigator blinded to the study interviewed patients daily. Results The incidence of PDPH was similar between the AT group (3.9%) and the WH group (4.0%). The total duration of all PDPHs was 5 days for the AT group and 15 days for the WH group. Both groups had a similar one-attempt success rate of 61% (AT group) and 62% (WH group). Failure to obtain cerebrospinal fluid occurred in only one in the AT group and two in the WH group. The incidence of PDPB was similar and the severity was mild in both groups. Conclusions The low complication and failure rates make these two types of smaller size spinal needle design good candidates for dural puncture procedures, such as spinal anesthesia, diagnostic lumbar punctures, and myelograms.

Doxorubicin-induced cardiomyopathy during pregnancy: Three case reports of anesthetic management for cesarean and vaginal delivery in two kyphoscoliotic patients

WITH childhood cancer survival rates on the rise, increasing numbers of female pediatric cancer patients are reaching childbearing age. The long-range effects of childhood chemotherapy can have significant clinical implications for these women. The toxicity of an antineoplastic drug given to the pediatric patient may not be fully apparent until other physical conditions in adulthood, such as pregnancy, force the issue. Pregnancy imposes significant physiologic changes and cardiovascular stress. The cardiotoxicity of one chemotherapeutic agent in particular, doxorubicin, is frequent in young females, potentially severely limiting myocardial growth in childhood, leading to a lifelong reduction in myocardial mass, which may result in a significantly decreased cardiac reserve in the child as she grows. 1,2 Pregnancy can unmask the cardiovascular damages caused by doxorubicin even from the remote past in otherwise asymptomatic patients. When these women require an anesthetic for vaginal or cesarean delivery, anesthesiologists should be aware of the possibility of cardiac failure, even in asymptomatic pregnant patients, if they have previously been treated with doxorubicin. The interaction of the long-term cardiotoxic effect of doxorubicin with pregnancy and anesthetic management has not been well described. We present two cases in which regional anesthesia, particularly combined spinal-epidural (CSE) technique, was used successfully for cesarean delivery and vaginal delivery in kyphoscoliotic patients with doxorubicin-induced cardiomyopathy. To our knowledge, this is the first report of the successful use of epidural and combined spinal-epidural technique in kyphoscoliotic pregnant patients with doxorubicin-induced cardiomyopathy presenting during pregnancy.

New onset heart failure in a 29-year-old : A case report of isolated left ventricular noncompaction

A previously healthy 29-year-old patient presented with new onset congestive heart failure. Based on findings on transthoracic echocardiogram (TTE) and cardiac magnetic resonance imaging (MRI) at an outside center, the patient was diagnosed as having a dilated cardiomyopathy with structural abnormalities in the ventricular septum and left ventricular (LV) apex suspicious for myocardial tumor. After referral to our center for further management, repeat TTE revealed findings characteristic of left ventricular noncompaction (LVNC) with severely depressed overall LV systolic function. Review of the outside cardiac MRI supported the diagnosis of LVNC. Final management consisted of traditional medical therapy for congestive heart failure, an implantable cardiac defibrillator (ICD), warfarin anticoagulation for the prevention of thromboembolism and referral for cardiac transplant.