Shmuel Evron

Remifentanil: a novel systemic analgesic for labor pain.

In a double-blind, randomized, controlled clinical trial, we compared the analgesic effect of remifentanil in patient-controlled IV analgesia (PCIA) during labor and delivery with the effect of an IV infusion of meperidine. Eighty-eight healthy term parturients who requested IV analgesia for labor pain were enrolled in the study and were randomly assigned to receive either increasing doses (0.27–0.93 &mgr;g/kg per bolus) of PCIA remifentanil (n = 43) or an IV infusion of meperidine 150 mg (range, 75–200 mg) per patient (n = 45). Remifentanil by the PCIA device was more effective and reliable analgesia for labor and delivery than IV infusion of meperidine. The visual analog score was lower (35.8 ± 10.2 versus 58.8 ± 12.8; P < 0.001) and the patient satisfaction score higher (3.9 ± 0.6 versus 1.9 ± 0.4; P < 0.001), with less of a sedative effect (1.2 ± 0.1 versus 2.9 ± 0.1; P < 0.001) and less hemoglobin desaturation (97.5% ± 1.0 versus 94.2% ± 1.5; P < 0.007). The percentage of analgesia failure (the rate of crossover from opiate to epidural analgesia) was less for remifentanil compared with meperidine (10.8% versus 38.8%; P < 0.007). There were no significant differences between groups in the mode of delivery or neonatal outcome. There were fewer nonreassuring abnormal fetal heart rate patterns, i.e., higher variability and reactivity with fewer decelerations, under remifentanil therapy as compared with meperidine (P < 0.001). In conclusion, an intermittent incremental regimen with repeated small-dose PCIA boluses of remifentanil provided effective and reliable analgesia during labor and delivery.

Role of Sonography in the Diagnosis of Retained Products of Conception

Objective. To present our experience with clinical and sonographic diagnosis of retained products of conception and to evaluate its correlation with histopathologic findings. Methods. This was a retrospective study on 156 patients admitted for retained products of conception. Women were referred because of 1 or more of the following: abdominal pain, bleeding, and fever. The status of the cervix was evaluated by bimanual examination. The diagnosis of retained products of conception was made when a sonographic finding of hyperechoic or hypoechoic material was seen in any part of the uterine cavity or the presence of a thickened endometrial stripe greater than 8 mm and an irregular interface between the endometrium and myometrium was found. One hundred twenty‐one women (77.6%) were admitted after dilation and curettage for abortion, and 35 (22.4%) were admitted after spontaneous labor. Results. Histopathologic reports confirmed the diagnosis of retained products of conception in 86 (71%) of 121 women in the postabortion group and in 17 (48.5%) of 35 women in the postpartum group. The overall false‐positive rate for sonographic diagnosis was 34%. For women after abortion and after delivery, the false‐positive rates were 28.9% and 51.5%, respectively. Conclusions. Reliance on common signs and symptoms to diagnose retained products of conception as well as the use of sonography is associated with an unacceptably high false‐positive rate, mainly after delivery. A more conservative approach to the treatment of retained products of conception is suggested.

Options for systemic labor analgesia

Purpose of review This article reviews the challenging practice of systemic analgesia as an alternative to epidural analgesia for labor pain, and places remifentanil within the context of opioid analgesics suitable for managing for labor pain. Recent findings Although systemic opioids have long been used for labor analgesia, they have become less popular because of frequent maternal and neonatal side effects. Recently, their efficacy has been questioned. Patient-controlled intravenous analgesia with fentanyl or sufentanil is currently the method of choice for achieving analgesia during early labor, when epidural analgesia is not feasible. Remifentanil has been suggested as the opioid of choice for labor analgesia, having the advantage of easy administration, predictable pharmacokinetics, and improved neonatal outcomes. The position of remifentanil in obstetric analgesia is now better understood, as reflected by the increasing number of reported studies describing its use. Summary Remifentanil is now gaining popularity. Remifentanil may be more suitable than other traditional opioids for inducing labor analgesia. Careful monitoring of the parturient and the newborn is recommended, however, to mitigate the potential for maternal and neonatal hypoxemia.

Difficult airway in obstetric anesthesia: a review.

Failed intubation and ventilation are important causes of anesthetic-related maternal mortality. The purpose of this article is to review the complex issues in managing the difficult airway in obstetric patients. The importance of prompt and competent decision making in managing difficult airways, as well as a need for appropriate equipment is emphasized. Four case reports reinforce the importance of a systematic approach to management. The overall preference for regional rather than general anesthesia is strongly encouraged. The review also emphasizes the need for professional and experienced team cooperation between the obstetrician and the anesthesiologist for the successful management of these challenging cases. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to break down the complex issues in managing the difficult airway in the obstetric patient, outline the reasons for difficult intubations in pregnancy, and describe the evaluation used to predict a difficult intubation.

Oligohydramnios: Maternal Complications and Fetal Outcome in 145 Cases

One hundred and forty-five cases of oligohydramnios in the second and third trimester were diagnosed by ultrasonography out of 25,000 obstetrics patients (0.58%). In this group, pregnancy complications included hypertension (22.1%) and bleeding in the second trimester (4.1%). We found a high incidence of meconium-stained amniotic fluid (29.1%), fetal distress (7.9%) and premature placental separation (4.2%). IUGR occurred in 24.5% of cases. Asphyxia during labor occurred in 11.5% and different other perinatal problems in 23.5%. Cesarean section was performed in 35.2% of these pregnancies. Seventeen percent of the cases presented as breech. Intrauterine fetal death occurred in 5.5% of these pregnancies. The gross perinatal mortality was 16% and the corrected perinatal mortality was 10.7%. The overall rate of fetal malformations was 11% and that of lethal malformations 4.8%. The skeletal (7.6%) and urinary system (4.1%) were the predominant systems affected. Oligohydramnios is associated with a higher rate of pregnancy complications and increased fetal morbidity and mortality, and thus termination should be considered when pulmonary maturity is present or in cases of fetal distress.

The effects of remifentanil or acetaminophen with epidural ropivacaine on body temperature during labor

PurposeEpidural analgesia is associated with hyperthermia during labor and presumably causes it, although no convincing mechanism has been postulated. It seems likely that fever associated with pyrogenic factors related to labor is suppressed by opioids, whereas it is expressed normally in patients given epidural analgesia. We examined this hypothesis and the possible etiology of temperature elevation in labor.MethodsIn this prospective, randomized, controlled study, we assessed 201 parturients during spontaneous labor. Analgesia was randomly provided with one of four treatment groups: (1) epidural ropivacaine alone, (2) IV remifentanil alone, (3) epidural ropivacaine plus IV remifentanil, and (4) epidural ropivacaine plus IV acetaminophen. At randomization, patients were normothermic. Intrapartum hyperthermia (≥38°C) was correlated to the analgesic technique.ResultsThe maximum increase in oral temperature was greatest in the ropivacaine group (0.7 ± 0.6°C) and least in the remifentanil group (0.3 ± 0.4°C; P = 0.013). The percentage of patients who became hyperthermic (≥38°C) during the first 6 h of labor was greatest in the ropivacaine group (14%) and least in the remifentanil-alone group (2%), but the difference was not statistically significant. The maximum forearm-finger gradients were lower (less vasoconstriction) in the remifentanil group when compared to the gradients in patients with epidural analgesia (1.4 ± 1.8 vs 3.0 ± 1.7, respectively; P < 0.001).ConclusionOur results are consistent with the theory that low-dose opioids inhibit fever in patients not given epidural analgesia. However, in view of the negative results, the hypothesis of epidural-induced hyperthermia may be questionable.

Intracranial subdural hematoma following dural puncture in a parturient with HELLP syndrome

PurposeTo present a case of postpartum bilateral intracranial subdural hematoma after dural puncture during attempted epidural analgesia for labour.Clinical featuresThis complication occurred following accidental dural puncture in a parturient with thrombocytopenia (99,000·μL−1) who subsequently developed the syndrome of hemolysis, elevated liver enzymes and low platelets. On the first postoperative day, postdural puncture headache (PDPH) developed. An epidural blood patch (EBP) was deferred to the third postoperative day because of a platelet count of 21,000·μL−1. However, the headache intensified from a typical PDPH to one which was not posturally related. A second EBP was abandoned after the injection of 5 mL of blood because of increasing headache during the procedure. Magnetic resonance imaging revealed bilateral temporal subdural hematomas. The patient was managed conservatively and discharged home without any sequelae.ConclusionIt is conceivable that thrombocytopenia together with possible abnormal platelet function increased the risk of subdural hematoma. Alternative diagnoses to PDPH should be considered whenever headache is not posturally related.RésuméObjectifPrésenter un cas d’hématome sous-dural intracrânien bilatéral du postpartum à la suite d’une ponction durale pendant l’administration d’analgésie épidurale pour le travail obstétrical.Éléments cliniquesLa complication est survenue après une ponction durale chez une parturiente qui présentait une thrombocytopénie (99 000·μL−1) et chez qui s’est ensuite développé un syndrome d’hémolyse, d’enzymes hépatiques élevés et d’un faible taux de plaquettes. Au premier jour postopératoire, la patiente a subi des céphalées post-ponction durale (CPPD). Un colmatage sanguin épidural (CSE) a été reporté au troisième jour postopératoire, étant donné la numération plaquettaire à 21 000·μL−1. Cependant, les céphalées ont augmenté jusqu’à n’avoir plus de lien avec la position du corps. Un second CSE a été abandonné après l’injection de 5 mL de sang, l’intervention augmentant la céphalée. L’imagerie par résonance magnétique a révélé des hématomes sous-duraux, temporaux, bilatéraux. La patiente a reçu un traitement conservateur et a quitté l’hôpital sans séquelles.ConclusionOn peut imaginer qu’une thrombocytopénie combinée à une dysfonction plaquettaire possible pourra accroître le risque d’hématome sous-dural. Il faut envisager un autre diagnostic que la CPPD chaque fois que la position n’est pas en cause.

The effect of intermittent versus continuous bladder catheterization on labor duration and postpartum urinary retention and infection: a randomized trial

STUDY OBJECTIVE To assess the effect of intermittent versus continuous bladder catheterization on labor duration and local anesthetic consumption. DESIGN Randomized, controlled, prospective, single-blind trial. SETTING University-affiliated hospital. PATIENTS 209 ASA physical status I and II, primiparous parturients who received patient-controlled epidural analgesia for labor. INTERVENTIONS Patients were randomly allocated to either the intermittent bladder catheterization group (Group IC; n = 109) or the continuous catheterization group (Group CC; n = 100). MEASUREMENTS Duration of the second stage of labor, dose of local anesthetics given, and primary outcomes were compared by group using the t-test for independent samples. Main secondary outcomes were postpartum urinary retention and rate of postpartum urinary tract infection (UTI; asymptomatic bacteruria). MAIN RESULTS Duration of the second stage of labor was longer in Group CC than Group IC: 105 +/- 72 vs. 75 +/- 52 min (P = 0.002). This finding was associated with increased local anesthetic dose requirement in Group CC during both stages of labor (73 +/- 25 mL vs. 63 +/- 26 mL; P = 0.005). The rate of UTI was similar (30%) in both study groups. CONCLUSION Intermittent bladder catheterization was associated with shorter second-stage labor and less local anesthetic, but the same frequency of postpartum urinary retention and UTI was seen with both catheterization groups.

Predistention of the epidural space before catheter insertion reduces the incidence of intravascular epidural catheter insertion

BACKGROUND:Accidental cannulation of an epidural vein is a common complication associated with epidural anesthesia or analgesia. On the basis of a pilot study and previous reports, we tested the hypothesis that predistention of the epidural space with saline before epidural catheterization would ease catheter insertion and decrease the incidence of this complication. METHODS:Two-hundred-three laboring women were randomly assigned to receive an epidural with loss of resistance technique with 2 mL (nondistention) or 5 mL saline (distention). In the distention group, the syringe plunger was held closed before epidural catheter insertion. Then in both groups, a test dose of 3 mL of 1.5% lidocaine was injected through the epidural catheter. RESULTS:There were fewer accidental intravascular catheter placements (2% vs 16%, P = 0.0001) in the distention group, and 91% of patients in this group did not have any unblocked segments versus 67% in the nondistension group (P = 0.0001). The difference in onset time of analgesia was small (5.0 ± 2 min vs 6 ± 3 min, P = 0.0001) and not clinically important. The quality of analgesia (visual analog scores and ropivacaine consumption) was similar between groups. CONCLUSIONS:Distention of the epidural space with 5 mL saline before epidural catheter insertion decreased the incidence of accidental venous cannulation and the number of unblocked segments.

Current understanding of the patient's attitude toward the anesthetist's role and practice in Israel: effect of the patient's experience

STUDY OBJECTIVE To assess the patients understanding and knowledge of the anesthesiologists role and responsibilities in the operating room and in other areas of hospital activity, and to delineate the effect of previous anesthetic experience on this knowledge. DESIGN Prospective study consisting of standard preanesthetic interview and questionnaire survey. SETTING Preoperative anesthetic clinic in a large central private hospital in Israel. PATIENTS 295 adult patients who were seen in the preanesthetic clinic in a 4-week period in May, 2000. INTERVENTIONS After patients were checked for exclusion criteria and given a standard preanesthetic interview, all adult patients presenting to this clinic were asked to participate in the study and complete a questionnaire, which was later evaluated statistically. RESULTS A total of 295 patients (90% response rate) took part in the study. Two hundred (67.8%) patients had previous experience with anesthetics (Group A), and 95 (32.2%) patients presented for the first time for anesthesia (Group B). Ninety-five percent in Group A and 94.7% of Group B believed that the anesthesiologist is a doctor. Ninety-three percent of Group A and 90.5% of Group B answered that the anesthesiologist himself administered the anesthetic drugs. As to the responsibility for the patients well-being during the operation and postoperatively, opinion was divided equally as to whether the surgeon or the anesthesiologist is responsible. The patients in both groups seemed to be well informed about the way anesthetic drugs act. Only 4% of patients of both groups knew about the anesthesiologists other duties outside the operation room. CONCLUSION If able to be extrapolated to all of Israel, our results show a high appreciation for the physician status of the anesthesia professional and role in safe recovery. Passive learning from a prior anesthetic experience did not appear to improve such appreciation.