Fred J. Spielman

Anesthetic management for obstetric hysterectomy: A multi-institutional study

A prospectively designed review of all obstetric hysterectomies performed in five university hospitals between November 1, 1984 and October 31, 1987 has been performed. There were 41,107 deliveries and 46 obstetric hysterectomies, an incidence of 0.11%. Twenty-five hysterectomies were elective and 21 were emergent. The indication for 11 of the 21 emergency hysterectomies was placenta previa and/or accreta. Women in the emergency group had greater intraoperative blood loss, were more likely to have intraoperative hypotension, and were more likely to receive donor blood than women in the elective group (P less than 0.05). Twelve patients (eight from the elective group and four from the emergency group) received continuous epidural anesthesia, and none required intraoperative induction of general anesthesia. There was no evidence that epidural anesthesia significantly affected blood loss, crystalloid replacement, or requirement for transfusion in the elective group. Abnormal placentation now represents a major indication for emergency obstetric hysterectomy. Furthermore, significant hemorrhage is more likely with emergency obstetric hysterectomy than with elective hysterectomy. Finally, elective cesarean hysterectomy is not a contraindication to performance of continuous epidural anesthesia.

Pregnant patients in the intensive care unit: A descriptive analysis

We present a descriptive analysis of experience with pregnant women in the intensive care units at a tertiary hospital. During the period from 1983 through 1990, 38 women were admitted to our intensive care units during their pregnancy or within 2 weeks postpartum. This was a rate of 1 per 400 pregnant patients. The mean age of these 38 women was 25 years; 68% of them were white and 32% were primigravidas. Nineteen of the 38 women were mechanically ventilated. Twelve women were admitted for hypertensive disease and 10 for adult respiratory distress syndrome. Maternal mortality was 18% (7/38). Follow-up was available for 33 women. The fetal and neonatal loss rate in this group was 4 of 33 pregnancies. In this case series of 38 very ill women, it was apparent that a team approach of obstetricians, anesthesiologists, and intensive care workers provided optimal management for the mother and child.

Pharmacokinetics and pharmacodynamics of local analgesia for laparoscopic tubal ligations

The pharmacokinetics and pharmacodynamics of lidocaine and bupivacaine, when used for laparoscopic sterilization under local anesthesia, are described in 21 patients. Under direct vision with the use of a laparoscope, local anesthetic solution was sprayed onto the fallopian tubes. Nine patients were administered 12 ml of lidocaine 2% (240 mg), and 12 patients received 20 ml of bupivacaine 0.5% (100 mg). Samples of venous blood were drawn at 0, 5, 10, 15, 20, 30, 60, and 120 minutes after the intraperitoneal placement of local anesthetic. Drug assays were performed by means of gas chromatography. The peak concentration of lidocaine was detected within 30 minutes. The mean concentration was 1.70 +/- 0.34 micrograms/mg (range, 1.19 to 2.07 micrograms/ml; convulsive level, 18 to 26 micrograms/ml). The peak concentration of bupivacaine was not evident until 60 minutes after injection. The mean concentration was 0.44 +/- 0.15 micrograms/ml (range, 0.20 to 0.77 micrograms/ml; convulsive level, 4.5 to 5.5 micrograms/ml). These findings may justify the use of larger volumes of these local anesthetics for more painful diagnostic laparoscopies whenever adhesions and/or extensive manipulation is anticipated.

Sodium Citrate Pretreatment in Elective Cesarean Section Patients

Thirty-two healthy term parturients undergoing elective cesarean section randomly received either no antacid (n = 10), 30 ml of 0.3 molar sodium citrate less than 60 min preoperatively (n = 11), or 30 ml of 0.3 molar sodium citrate longer than 60 min preoperatively (n = 11). Immediately after delivery, the stomach was empatied as completely as possible through a # 18 Salem Sump tube passed orally. Mean gastric pH in the three groups was 1.8 ± 2.7 (SD), 5.0 ± 1.5, and 2.7 ± 1.2, respectively. Gastric pH was significantly higher in the short interval group than in either the control group or in patients receiving their sodium citrate more than 60 min in advance. Gastric volumes were similar. All control patients had a gastric pH less than 2.5. Nine percent of patients receiving sodium citrate less than 60 min in advance arid 50% of patients receiving their sodium citrate longer than 60 min in advance had a pH of less than 2.5. Volumes exceeding 25 ml occurred with equal frequency. No patient in the short interval group had a combination of both pH of less than 2.5 and a volume exceeding 25 ml. This combination occurred with equal frequency in control patients (64%) and in those patients receiving their sodium citrate more than 60 min in advance (50%). We conclude that sodium citrate effectively increases gastric pH when given less than 60 min prior to the induction of anesthesia.

Prevention of fetal movement during invasive procedures with pancuronium bromide

The use of fetal intramuscular pancuronium (0.5 mg) to temporarily arrest fetal movement during antenatal intervention in six instances is reported. Successful arrest of movement without adverse side effects was observed. The use of this technique eliminates the need for the excessive and potentially dangerous maternal sedation currently used to minimize fetal movement.

Subarachnoid and epidural anaesthesia for patients with epidermolysis bullosa

Successful anaesthetic management of two patients with severe epidermolysis bullosa was accomplished using subarachnoid and epidural blockade. !n order to avoid complications of regional anaesthesia, antiseptic preparation of the skin should not involve scrubbing nor should adhesive tape be used 10 secure catheters. In addition local infiltration of the skin is best avoided. The potential complications of skin and oral mucosal damage associated with mask or endotracheal inhalation anaesthesia was avoided.RésuméOn a eu recours à la rachi-anesthésie el au bloc péridural pour I ’anesthésie de deux patients afftigés d’épider-molyse bulleuse. Pour prevenir les complications d’ordre dermatologique, le badigeonnage de la peau doit se faire sans frottage et on doit éviter I’emploi de tout pansement adhésif ou ruban gommé. II est aussi préférable de ne pas infiltrer la peau localement. En procédant sous anesthésie régionale, les dommages à la peau ou uux muqueuses par les contacts du masque ou du tube endotrachéal out été évités.

Anesthesia and Analgesia–Related Preferences and Outcomes of Women Who Have Birth Plans

INTRODUCTION This study described anesthesia and analgesia-related preferences and outcomes of women who used a birth plan for labor and birth. METHODS A prospective cohort study was conducted (N = 63). Data were abstracted from medical records, birth plans, and a follow-up survey. Descriptive statistics were used for analysis. RESULTS Women who elected birth plans were primarily white, college-educated, primigravida, and under the care of a certified nurse-midwife. One-third of births were induced, 10% required instrumentation, and 29% were cesarean births. Nearly every birth was associated with at least 1 labor and birth complication, although most complications were minor. Analgesic preferences were reported to be the most important birth plan request. Greater than 50% of women requested to avoid epidural analgesia; however, 65% of women received epidural analgesia. On follow-up, greater than 90% of women who received epidural analgesia reported being pleased. The majority of women agreed that the birth plan enhanced their birth experiences, added control, clarified their thoughts, and improved communication with their health care providers. DISCUSSION Anesthesia and analgesia-related preferences were an important component of the birth plans. The majority of women favorably viewed the use of a birth plan, whether or not preferences were fulfilled or complications occurred.

Nifedipine enhances the cardiac toxicity of magnesium sulfate in the isolated perfused Sprague-Dawley rat heart

Magnesium sulfate is commonly used in tocolytic regimens and as prophylaxis against seizures. Nifedipine may be used simultaneously in either situation. With the isolated perfused rat heart model (Sprague-Dawley rats), we investigated the effects of these agents on cardiac function. Whereas each agent alone depressed cardiac performance, the two drugs together had maximal depressive effects on the heart.

Postoperative conversion disorder in a pediatric patient.

According to the Diagnostic and Statistical Manual IV (DSM IV), conversion disorder is classified as a somatoform illness and defined as an alteration or loss of physical function because of the expression of an underlying psychological ailment. This condition, previously known as hysteria, hysterical neurosis, or conversion hysteria occurs rarely, with an incidence of 11–300 cases per 100 000 people (American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edn. Washington, DC: American Psychiatric Association, 1994). Presentation after an anesthetic is exceptional. After thorough review of the literature, fewer than 20 cases have been documented, with only two instances in patients younger than 18 years of age after general anesthesia; both were mild in nature. We present a severe case of postoperative conversion disorder that developed upon emergence from anesthesia in a previously healthy 16‐year‐old girl following direct laryngoscopy with vocal fold injection.

The effect of human amniotic fluid on the isolated perfused rat heart

To test the hypothesis that amniotic fluid directly affects cardiac function, isolated rat hearts were perfused with varying concentrations of centrifuged and filtered human amniotic fluid. The most consistent change seen was a dose-dependent decrease in coronary flow rate. With 10% concentrations, a wide spectrum of changes was seen in both a positive and a negative direction for left ventricular pressure and change in pressure with respect to time, which were closely correlated with the degree of decrease in coronary flow rate. If amniotic fluid has a direct role in depressing cardiac function in amniotic fluid embolism, it may act by decreasing coronary flow rather than by directly suppressing myocardial activity.