M. Rosen

Maternal opinion about analgesia for labour. A controlled trial between epidural block and intramuscular pethidine combined with inhalation.

In a randomised controlled trial epidural analgesia with bupivacaine 0·5% (mean dose 112·8 mg) was compared with pethidine (mean dose 200 mg) and inhalational analgesia in primipara (28 and 30 mothers) and multipara (17 and 18 mothers). Mothers who had an uneventful pregnancy and labour and agreed to have either treatment were studied during labour and followed‐up at interviews for 5 months after delivery. Epidural block was rated significantly superior in respect of pain relief and comfort, there were no differences between the groups in reports of perineal discomfort. Twice as many primipara required forceps delivery after epidural block. Very few mothers, in each group, reported something missing in their experience of childbirth. Two thirds of each group would use the same method again. Epidural block can therefore be recommended to uncommitted mothers as a satisfying and effective method of pain relief for labour.

APPARATUS FOR PATIENT-CONTROLLED ADMINISTRATION OF INTRAVENOUS NARCOTICS DURING LABOUR

The intermittent intravenous administration of narcotic analgesics had advantages over intramuscular administration, but is often impracticable. The design of a prototype apparatus is described, from which analgesic, pethidine, can be self-administered intravenously during labour. The apparatus consists of a syringe pump and control system from which the patient can demand an increment of analgesic. The minimum interval between increments and the dose of the increment are preset. A demand for analgesia is only successful when the patient passes a reaction-time test, subsequently modified. The apparatus has been used by forty-two mothers in labour. The mean total dose self-administered (2.2 mg/kg) was well within the prescribed limits, suggesting that mothers regulated their demand. The apparatus appears acceptable and safe in labour. The apparatus will probably be of value in comparative studies of analgesics.

Intra‐articular morphine and bupivacaine analgesia after arthroscopic knee surgery

We assessed the effectiveness of intra‐articular solutions of morphine, bupivacaine with adrenaline and a combination of both, compared with placebo in facilitating mobilisation and reducing postoperative pain and analgesic requirements for 24 h after operation. Forty patients undergoing arthroscopic knee surgery were studied in a double‐blind, randomised, controlled trial. All treatments proved more effective than placebo in facilitating earlier mobilisation and in decreasing postoperative pain as measured by visual analogue scale. Morphine alone provided the best analgesia and significantly decreased analgesic consumption for 24 h after surgery. We conclude that 1 mg of intra‐articular morphine provides effective pain relief following arthroscopic knee surgery and that the addition of bupivacaine is of no benefit.

Gastric emptying and small bowel transit times in volunteers after intravenous morphine and nalbuphine

Gastric emptying half‐times and small intestinal transit times were measured in a double‐blind crossover study of 17 volunteers who received an intravenous injection of nalbuphine (5 or 10 mg), morphine (5 mg) or placebo. Both times were monitored using a gamma camera after a radioactive test meal and gastric emptying half‐time was calculated. Small intestinal transit time was measured by the appearance of radioactivity in the caecum and also of hydrogen in end tidal air. Gastric emptying was prolonged over placebo by nalbuphine 10 mg, which had more effect than nalbuphine 5 mg or morphine 5 mg: morphine 5 mg had less effect than nalbuphine 5 mg. Small intestinal transit time was prolonged over placebo by nalbuphine 10 mg more than by nalbuphine 5 mg or morphine 5 mg, which had approximately equal effects. In these respects, the potency ratio of nalbuphine appears roughly equivalent to morphine. Small intestinal transit times measured by end tidal hydrogen concentration and gamma camera showed close agreement.

Self-administered intravenous and intramuscular pethidine.: A controlled trial in labour

In a randomised controlled trial of mothers in labour intramuscular pethidine 150 mg, repeated if necessary, was compared with self‐administered intravenous pethidine (0·25 mg/kg available at 10‐min‐intervals). Each mother agreed to have either method of pain relief and could opt for epidural block. The intramuscular group had significantly more pethidine than the intravenous group (mean differences, primipara 29 mg; multipara 16 mg). Ratings by mothers of the pain of 1st, 2nd stage and overall (analogue scores and gradings) were consistently better for the intravenous group although not significantly different. There were no differences in mean Apgar scores between the babies in the groups. In mothers who do not choose epidural block, similar pain relief is afforded by adequate intramuscular pethidine or self‐demand intravenous pethidine; however, intravenous self‐administration is more efficient since the pain relief is achieved with a lower dose of pethidine.

The effectiveness of pre-operative advice to stop smoking: a prospective controlled trial.

Patients who smoke cigarettes suffer increased postoperative morbidity. A prospective, controlled trial was designed to evaluate the effectiveness of written pre‐operative advice to stop smoking before admission for elective surgery and to record the duration of abstinence immediately before the operation. Although the advice was ineffective in persuading patients to stop smoking, it was associated with a reduction in the amount of tobacco consumed. Nicotine and carbon monoxide have important short‐term adverse effects but 15% of all patients continued to smoke within an hour of surgery. If patients are unable to give up cigarette smoking completely, it is still worthwhile stopping on admission to hospital.

A jet nebuliser for delivery of topical anaesthesia to the respiratory tract A comparison with cricothyroid puncture and direct spraying for fibreoptic bronchoscopy

Topical anaesthesia of the respiratory tract for fibreoptic bronchoscopy was compared, in a single‐blind study, inhaled from a simple and inexpensive jet nebuliser, administered by cricothyroid injection or by a ‘spray‐as‐you‐go technique’. Each technique was supplemented by spraying lignocaine through the fibrescope and intravenous fentanyl‐droperidol sedation. Inhaled nebulisation was successfully used for 96% (46 of 48) of patients, was safe, effective and acceptable to the patient and bronchoscopist. The cricothyroid injection method produced better conditions than nebulisation in patients who had diagnostic bronchoscopy. The nebuliser technique is as satisfactory as the spraying technique in patients for diagnostic bronchial lavage in whom bleeding from a cricothyroid puncture is unacceptable. Patients who used the nebuliser were more satisfied. This technique may also be a useful method for ‘awake’ intubation.

Propofol induction and maintenance with nitrous oxide in paediatric outpatient dental anaesthesia. A comparison with thiopentone-nitrous oxide-halothane.

Intravenous induction of anaesthesia with propofol (3.5 mg/kg) and maintenance boluses (I mg/kg), with 30% oxygen and 70% nitrous oxide, were compared with intravenous thiopentone induction (5 mg/kg) followed by 30% oxygen and 70% nitrous oxide, supplemented with 2 to 3% halothane in children aged 2–11 years who underwent dental extractions. Both techniques were found to he acceptable in clinical practice. Recovery from anaesthesia was assessed by the time taken to reach clinically‐defined milestones. Times to open eyes, give name, stand unaided, and time to discharge were all 3 to 7 minutes shorter in those who had the propofol technique compared with those who had thiopentone‐halothane (p < 0.05). These indices of recovery were more sensitive than the Steward score.

The effectiveness of antenatal education

A SURVEY of antenatal education methods, their uptake and value was un dertaken in Cardiff. Seven hundred and forty four women were interviewed during their first pregnan cies. The effectiveness of an tenatal education was assessed objectively in terms of acquisition of knowledge and the level of anxiety at the time of first attendance, at 35 weeks gestation, and soon after the birth of the baby. Initial knowledge and its acquisition during pregnancy was particularly poor in the lower socio-economic groups and in younger women. In these patients reading dif ficulties were common. Mothercraft classes were beneficial, but attendance by those most in need was very poor. Acquisition of knowledge by any means, including attendance at mothercraft classes, reduced maternal anxiety in late pregnancy. Suggestions for improving the nature and delivery of antenatal education are made.

Enflurane as an analgesic in labour

A comparison of the analgesic efficacy of enfrurane 1% in air with Entonox (50% nitrous oxide in oxygen) was performed in 20 consenting women during the first stage of labour. The two drugs were given in a random sequence to each woman, who also acted as her own control. Pain scores were significantly lower with enfrurane than Entonox, although drowsiness scores were higher. No untoward effects were reported with either agent. The use of enflurane as an analgesic in the first stage of labour warrants further investigation.