Herbert M. Floyd

Neonatal Neurobehavioral Responses After Epidural Anesthesia for Cesarean Section Using Lidocaine and Bupivacaine

: We compared the early neonatal neurobehavioral responses after lumbar epidural anesthesia for elective cesarean section using 2% lidocaine (n = 10) and 0.5% bupivacaine (n = 21). We tested the infants at 4 and 24 hr after birth and found that the neonates in the lidocaine group scored as well as those in the bupivacaine group on all parameters of the early neonatal neurobehavioral score (ENNS). In fact on one parameter, sucking response at 24 hr, the neonates in the lidocaine group scored significantly higher than those in the bupivacaine group. We concluded that 2% lidocaine does not compromise newborn outcome when compared to 0.5% bupivacaine and that it provides a satisfactory choice for use during elective cesarean section in healthy pregnancies. This conclusion is important in the light of the current concern over the safety of the use of chloroprocaine and bupivacaine in obstetric anesthesia.

Determination of an Effective Dose of Intrathecal Morphine for Pain Relief After Cesarean Delivery

UNLABELLED Very small doses of intrathecal (i.t.) morphine (25-200 microg) have been used in an effort to provide effective postoperative pain relief while minimizing side effects after cesarean delivery. We performed a double-blinded study in 40 patients presenting for elective cesarean delivery in which i.t. morphine was administered along with oral hydrocodone/acetaminophen and other medications commonly administered after cesarean delivery. We administered i.t. morphine by up-down sequential allocation of doses. For the purposes of this study, adequate postoperative analgesia was defined as comfort not requiring i.v. morphine for 12 h after spinal anesthesia with bupivacaine, fentanyl, and morphine. In addition, a time and cost comparison was performed for study patients receiving intrathecal morphine compared with a historical group of patients receiving patient-controlled analgesia with i.v. morphine. We were unable to determine with meaningful precision a dose of i.t. morphine to provide analgesia in this context. However, very small doses of i.t. morphine combined with oral hydrocodone/acetaminophen and other medications commonly prescribed after cesarean delivery provided postoperative pain relief with no more time commitment than patient-controlled analgesia (148 +/- 61 vs 150 +/- 57 min) and with significantly less acquisition cost (

Sodium Citrate Pretreatment in Elective Cesarean Section Patients

15.13 +/-

Antacid anticholinergic regimens in patients undergoing elective Caesarean Section

4.40 vs

Chloroprocaine vs bupivacaine for lumbar epidural analgesia for elective cesarean section

34.64 +/-

The effectiveness of low dose droperidol in controlling nausea and vomiting during epidural anesthesia for cesarean section

15.55). IMPLICATIONS When used along with oral analgesics, very small doses of spinal morphine provide adequate pain relief after cesarean delivery. Spinal anesthetics, oral analgesics, and other medications commonly prescribed to treat side effects after cesarean delivery contribute significantly to this analgesia. When small doses of spinal morphine are used in this setting, they provide adequate analgesia and patient satisfaction that is time- and cost-effective.

NEONATAL NEUROBEHAVIORAL RESPONSES AFTER EPIDURAL ANESTHESIA FOR CESAREAN SECTION WITH LIDOCAINE AND BUPIVACAINE

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.

Sodium citrate premedication in elective caesarean section patients

The pH and volume of gastric contents were examined in 60 patients undergoing elective Caesarean Section under thiopentone, nitrous oxide-oxygen, succinylcholine anaesthesia. All patients received Gelusil® 30 ml per os preoperatively, while 20 were given atropine 7 μg.kg-1 and another 20 glycopyrrolate 4 μg.kg-1 intramuscularly along with Gelusil®. Following tracheal intubation, gastric fluid was sampled through an orally placed 18 French Salem Sump tube.After Gelusil® alone, the mean gastric fluid pH was 4.54 ± 2.45 (SD) while it was significantly higher following the combined use of antacid and atropine (6.78 ± 1.20) or antacid and glycopyrrolate (6.42 ± 1.72), (P < 0.01). Differences in gastric fluid volume between the groups were insignificant.All three regimens produced a gastric pH greater than 2.5 when given less than 75 minutes before sampling. When the premedication to sampling interval exceeded 75 minutes the addition of atropine or glycopyrrolate decreased the incidence of gastric pH less than 2.5 from 47 per cent in patients given Gelusil® alone to 6 per cent and 14 per cent, respectively. In comparison to Gelusil® alone, this difference was significant with atropine (P < 0.05) but not with glycopyrrolate. Atropine and glycopyrrolate respectively produced 6 per cent and 7 per cent incidences of pH lower than 2.5 combined with gastric volume greater than 25 ml, which were significantly lower than was observed with Gelusil® alone (P < 0.05).This study demonstrates that the addition of atropine or glycopyrrolate to Gelusil® premedication provides additional protection against the consequences of aspiration, especially when the premedication to anaesthetic induction period is prolonged.RésuméLe pH et le volume du contenu gastrique ont été mesurés sur 60 femmes anesthésiées au thiopental, protoxyde-oxygène et succinylcholine lors de césariennes en chirurgie réglée. Elles avaient toutes reçues Gelusil® 30 ml per os à la période préopératoire, médication à laquelle furent ajoutés atropine 7 µg.kg-1 dans 20 cas et glycopyrrolate 4 µg.kg-1 dans 20 autres cas. Après l’intubation endotrachéale, le liquide gastrique fut aspiré à l’aide d’une sonde Salem Fr 18.Après Gelusil® seul, le pH moyen du liquide gastrique a été mesuré à 4.54 ± 2.45 (ET) alors qu’il fut plus élevé de façon significative à la suite de l’association antiacide-atropine (6.78 ± 1.2) ou antiacide-glycopyrrolate (6.42 ± 1.72), (P < 0.01). La différence de volume entre les groupes n’a pas été significative.Les trois prémédications ont produit un pH gastrique de plus de 2.5 lorsqu’administrées à moins de 75 minutes avant l’échantillonnage. Lorsque l’intervalle entr la prémédication et l’échantillonnage a dépassé 75 minutes l’addition d’atropine ou de glycopyrrolate a diminué l’incidence d’acidité à pH de moins de 2.5 de 40 per cent pour les patientes au Gelusil® seul à 6 pour cent et 14 pour cent respectivement pour les autres prémédications. En comparaison avec le Gelusil® seul, cette différence a été significative pour l’atropine (P < 0.05) mais non pour le glycopyrrolate. L’atropine et le glycopyrrolate ont permis de réduire à 6 et 7 pour cent respectivement l’incidence d’acidité plus basse que 2.5 s’associant à un volume gastrique plus grand que 25 ml, ce qui était significativement plus bas qu’avec le Gelusil® seul (P < 0.05).Cette étude tend à démontrer que l’addition d’atropine ou de glycopyrrolate au Gelusil® en prémédication permet une protection additionnelle contre les effets nocifs de l’aspiration lorsque la période qui sépare la prémédication de l’induction se prolonge.

THE EFFECTIVENESS OF LOW DOSE DROPERIDOL IN CONTROLLING NAUSEA AND VOMITING DURING EPIDURAL ANESTHESIA FOR CESAREAN SECTION

: The incidence and degree of hypotension, time to establish surgical analgesia, and several other maternal and fetal variables were studied when 2-chloroprocaine, 3 per cent, and bupivacaine, 0.5 per cent, were used for epidural analgesia in 30 women undergoing elective cesarean section. Surgical analgesia occurred 8 min sooner (P less than 0.001) with chloroprocaine (14 +/- 1 min) than with bupivacaine (22 +/- 2 min). Blood pressure values were significantly lower with chloroprocaine than with bupivacaine during the 18--to-32 min interval after local anesthetic injection, while pulse rates were higher (P less than 0.05) at 18, 20, and 22 min. Hypotension necessitating treatment with ephedrine occurred in 33 per cent of chloroprocaine-treated subjects, compared with 13 per cent of those receiving bupivacaine. Newborn outcome was excellent in both groups, as reflected by umbilical vessel blood-gas values, times to sustained respiration, and 5-min Apgar scores. The authors conclude that chloroprocaine disturbs maternal cardiovascular status more than does bupivacaine when used for cesarean section epidural analgesia. However, chloroprocaine can be employed safely in normal pregnancies if maternal hypotension is corrected rapidly.

Tracheal Intubation: Theory and Practice.

The antiemetic efficacy of 0.5 mg of droperidol was evaluated in 128 term parturients undergoing elective and non-urgent cesarean section with epidural anesthesia. Following delivery, parturients received intravenously either 0.5 mg of droperidol or normal saline in a double-blinded fashion. Droperidol decreased nausea after delivery from 41 to 13% (P=0.001). There was no significant decrease in the incidence of vomiting. Analysis of the data using logistic regression analysis showed that increasing age (P = 0.002), hypotension after delivery (P = 0.040), and vomiting prior to delivery (P = 0.017) were associated with increased nausea after delivery. No extrapyramidal symptoms or significant changes in pulse rate or blood pressure were associated with droperidol administration. We conclude that 0.5 mg of intravenous droperidol decreases nausea in term parturients undergoing non-urgent cesarean section with epidural anesthesia without producing unwanted side-effects.