Somboon Thienthong

Spinal versus epidural anesthesia for cesarean delivery in severe preeclampsia: a prospective randomized, multicenter study.

In this randomized, multicenter study we compared the hemodynamic effects of spinal and epidural anesthesia for cesarean delivery in severely preeclamptic patients. The epidural group (n = 47) received 2% lidocaine with epinephrine 1:400,000, 18–23 mL, followed by 3 mg of morphine after delivery. The spinal group (n = 53) received 2.2 mL of 0.5% hyperbaric bupivacaine plus 0.2 mg morphine. We hypothesized that the lowest MAP (mean arterial blood pressure, the primary outcome) during the delivery period would have to be at least 10 mm Hg less in the spinal group to be of clinical importance. We found that there was a statistically significant difference in MAP, with more patients in the spinal group exhibiting hypotension (P < 0.001). Although the incidence of hypotension (systolic arterial blood pressure, SAP ≤100 mm Hg) was more frequent in the spinal group than in the epidural group (51% versus 23%), the duration of significant hypotension (SAP ≤100 mm Hg) was short (≤1 min) in both groups. There was more use of ephedrine in the spinal group than in the epidural group (median, 6 versus 0 mg) but hypotension was easily treated in all patients. Neonatal outcomes assessed by Apgar scores and the umbilical arterial blood gas analysis were similar in both groups. Adverse neonatal outcomes (5-min Apgar score <7 and umbilical arterial blood pH <7.20) were found in only 2 premature newborns (weight <1500 g) who were born without maternal hypotension after regional anesthesia. We conclude that the results of this large prospective study support the use of spinal anesthesia for cesarean delivery in severely preeclamptic patients.

Peridural methylprednisolone and wound infiltration with bupivacaine for postoperative pain control after posterior lumbar spine surgery: a randomized double-blinded placebo-controlled trial.

Study Design. A randomized, double-blind placebo controlled trial in multimodal analgesia for postoperative pain was conducted. Objective. To examine whether combination of corticosteroid and bupivacaine administered in patients undergoing posterior lumbosacral spine surgery reduces postoperative morphine consumption, back and leg pain relief, and improves functional disability and general health status. Summary of Background Data. Patients with lumbar spine surgery had moderate to severe postoperative pain. Administration of corticosteroid or injection of local anesthetic agent has been additive treatment methods for opioid drugs. There is uncertainty as to whether corticosteroid and bupivacaine combination improves outcomes in lumbosacral spine surgery. Methods. A total of 103 patients who were scheduled to undergo elective posterior lumbar discectomy, decompressive laminectomy with or without instrumented fusion for degenerative spinal diseases, received either methylprednisolone locally applied to the affected nerve roots (and bupivacaine was infiltrated into the wound) or injected placebo. Morphine consumption and pain scores were recorded at 1, 2, 3, 6, 12, 24, and 48 hours after surgery. Oswestry Index and Short Form SF-36 scores were recorded before surgery and at 1 and 3 months later. Results. Demographic data between the 2 groups were comparable. The cumulative morphine dose and postoperative pain was significantly lower in the study group than in the placebo group (P = 0.01 and P = 0.001, respectively). When performing subgroup analyses, the beneficial effects were found in all groups of surgery but could not demonstrated statistically significant difference for all subgroup comparisons. There was no significant difference between the 2 groups with regard to pain on cough, Oswestry Index, and SF-36 scores. No complications were associated with the perioperative use of methylprednisolone or bupivacaine. Conclusions. Administration of methylprednisolone-bupivacaine provided a favorable effect immediately after posterior lumbosacral spine surgery for discectomy, decompression, and/or spinal fusion without complication.

Effect of parecoxib on postoperative pain after lumbar spine surgery: a bicenter, randomized, double-blinded, placebo-controlled trial.

Study Design. A bicenter randomized, patients, healthcare providers, and data collectors blind placebo-controlled trial in multimodal analgesia for postoperative lumbar spine surgery was conducted. Objective. To assess the efficacy and safety of parecoxib on postoperative pain management after posterior lumbar spine surgery. Summary of Background Data. Systematic reviews suggest that cyclo-oxygenase-2 inhibitors are an effective treatment for acute postoperative pain. However, previous trials on lumbar spine surgery showed equivocal efficacy of cyclo-oxygenase-2 inhibitors for postoperative pain relief. Methods. In this study, 120 patients undergoing posterior lumbar discectomy, spinal decompression, or spinal fusion were stratified based on the surgical procedure to 3 groups (n = 40) and randomly allocated to receive multidoses of parecoxib 40 mg/dose or placebo. Efficacy was assessed by total morphine used from patient-controlled analgesic pump, pain intensity, pain relief, and the patient’s subjective rating of the medication. Results. Parecoxib 40 mg reduced the total amount of morphine required over 48 hours by 39% relative morphine reduction compared with placebo (P = 0.0001). Pain at rest was reduced by 30% (P = 0.0001). Ninety percent of patients given parecoxib experienced at least 50% maximum total pain relief compared with 58% treated with placebo. The number-needed-to-treat for 1 patient to have at least half pain relief was 3.1 (2.0–4.6). Patients’ subjective rating of the medication was described as “excellent, good, and fair” by 48%, 43%, and 8% in the parecoxib group, respectively, compared with 21%, 50%, and 28% of placebo patients (P = 0.004). Overall adverse effects of patients receiving parecoxib and morphine were comparable to those receiving morphine alone. Conclusion. The present study demonstrates that the perioperative administration of parecoxib with patient-controlled analgesic morphine after lumber spine surgery resulted in significantly improved postoperative analgesic management as defined by reduction in opioid requirement, lower pain scores, and higher patients’ subjective rating of the medication.

Cardiac arrest after spinal anesthesia in Thailand: a prospective multicenter registry of 40,271 anesthetics.

BACKGROUND AND OBJECTIVES: As part of the Thai Anesthesia Incidents Study of anesthetic adverse outcomes, we evaluated the incidence and factors related to cardiac arrest during spinal anesthesia. METHODS: During a 12-mo period (March 1, 2003, to February 28, 2004), a prospective, multicenter registry of patients receiving anesthesia was initiated in 20 hospitals (7 university, 5 tertiary, 4 general, and 4 district hospitals) across Thailand. Anesthesia personnel reported patient-, surgery-, and anesthetic-related variables and adverse outcomes, including cardiac arrest during spinal anesthesia (defined as the time period from induction of spinal anesthesia until the end of operation). Adverse event specific forms were recorded within 24 h of an anesthetic procedure whenever a specific adverse event occurred. Univariate and multivariate analysis were used to identify factors related to cardiac arrest during spinal anesthesia. A P value <0.05 was considered significant. RESULTS: In the registry of 40,271 cases of spinal anesthesia, there were 11 cardiac arrests, corresponding to an incidence of 2.73 (95% CI: 1.12–4.34) per 10,000 anesthetics. The mortality rate was 90.9% among patients who arrested. Among 11 patients who arrested, there were 5 cases of cesarean delivery and 6 cases of extremity surgery, including hip surgery. In 4 patients (36.3%), the anesthetic contributed directly to the arrest (high sympathetectomy, local anesthetic overdose, or lack of electrocardiography monitoring), whereas some arrests were associated with specific events (cementing of prosthesis, massive bleeding, suspected pulmonary embolism, and suspected myocardial infarction). From multivariate analysis, the risks of cardiac arrest during anesthesia were shorter stature (odds ratio 0.944 [95% CI: 0.938–0.951], P < 0.001), longer duration of surgery (odds ratio 1.003 [95% CI: 1.001–1.005], P = 0.002), and spinal anesthesia administered by the surgeon (odd ratio 23.508 [95% CI: 6.112–90.415], P < 0.001), respectively. CONCLUSION: The incidence of cardiac arrest during spinal anesthesia was infrequent, but was associated with a high mortality rate. If the surgeon performed the spinal anesthetic, this was a significant factor associated with cardiac arrest. Increasing the number of anesthesiologists, improving monitoring guidelines for spinal anesthesia and improving the nurse-anesthetist training program may decrease the frequency of arrest and/or improve patient outcome.

A placebo-controlled, double-blind, randomized study of single-dose intravenous diclofenac for pain relief after a cesarean section.

BACKGROUND This study was conducted to avoid the pain of an intramuscular injection of diclofenac after a cesarean section, by modifying it to an intravenous infusion by diluting it with 5% dextrose in 100 mL of water. OBJECTIVE The aim of this study was to determine the efficacy of a single-dose modified diclofenac being given intravenously, instead of intramuscularly, for pain relief after a cesarean section. STUDY DESIGN A double-blind, randomized controlled trial was conducted. PARTICIPANTS We enrolled 30 patients who underwent cesarean sections with Pfannenstiel skin incision. METHODS All patients received 2.2-2.5 mL of 0.5% bupivacaine with 0.2 mg morphine for spinal anesthesia. The participants were equally and randomly allocated to two groups to receive intravenous diclofenac or placebo at 12 hours postoperatively. Both groups received the same regimen for postoperative pain control. MAIN OUTCOME MEASUREMENTS The severity of postoperative pain was measured directly using a verbal numerical rating scale (0-10) and a pain-relief scale (1-4), and indirectly from the amount of tramadol used. RESULTS The characteristics of the two groups of patients were similar. The mean postoperative pain relief at 24 hours in the study group was better than that in the control group (3.14 ± 0.66 vs. 2.13 ± 0.99; p < 0.05). The severity of postoperative pain at 24 hours and the amount of tramadol used were not different between groups. CONCLUSION Intramuscular diclofenac (75 mg), modified by diluting it with 5% dextrose in 100 mL of water, for intravenous administration in combination with spinal morphine (0.2 mg) provided good analgesia after a cesarean section within 24 hours when assessed by the pain-relief scale; however, the mean pain intensity was not different.

Spinal versus epidural anesthesia for cesarean delivery in severe preeclampsia : A prospective randomized, multicenter study

In this randomized, multicenter study we compared the hemodynamic effects of spinal and epidural anesthesia for cesarean delivery in severely preeclamptic patients. The epidural group (n = 47) received 2% lidocaine with epinephrine 1:400,000, 18-23 mL, followed by 3 mg of morphine after delivery. The spinal group (n = 53) received 2.2 mL of 0.5% hyperbaric bupivacaine plus 0.2 mg morphine. We hypothesized that the lowest MAP (mean arterial blood pressure, the primary outcome) during the delivery period would have to be at least 10 mm Hg less in the spinal group to be of clinical importance. We found that there was a statistically significant difference in MAP, with more patients in the spinal group exhibiting hypotension (P < 0.001). Although the incidence of hypotension (systolic arterial blood pressure, SAP < or =100 mm Hg) was more frequent in the spinal group than in the epidural group (51% versus 23%), the duration of significant hypotension (SAP < or =100 mm Hg) was short (< or =1 min) in both groups. There was more use of ephedrine in the spinal group than in the epidural group (median, 6 versus 0 mg) but hypotension was easily treated in all patients. Neonatal outcomes assessed by Apgar scores and the umbilical arterial blood gas analysis were similar in both groups. Adverse neonatal outcomes (5-min Apgar score < 7 and umbilical arterial blood pH < 7.20) were found in only 2 premature newborns (weight < 1500 g) who were born without maternal hypotension after regional anesthesia. We conclude that the results of this large prospective study support the use of spinal anesthesia for cesarean delivery in severely preeclamptic patients.