Unyime S. Ituk

Retrospective comparison of ephedrine and phenylephrine for the treatment of spinal anesthesia induced hypotension in pre-eclamptic patients.

Abstract Objective: To compare neonatal acid base status in parturients who underwent cesarean delivery and received either ephedrine or phenylephrine boluses for the treatment of spinal anesthesia induced hypotension. Research design and methods: After institutional review board approval, the perioperative database of the University of Iowa Hospitals and Clinics was used to identify all women diagnosed with pre-eclampsia and had cesarean delivery under spinal anesthesia for the period 1 January 2005 to 31 July 2014. Data retrieved included patient demographics, indication for cesarean delivery, severity of pre-eclampsia, dose of vasopressor, neonatal umbilical artery pH and Apgar scores. Main outcome measures: Primary outcome was umbilical artery pH. Results: Data for 146 patients was included in the analysis. Ephedrine was used in 57 patients (group E) and phenylephrine in 89 (group PE) patients. The median umbilical artery pH was 7.30 (IQR 7.20–7.30) and 7.30 (IQR 7.20–7.30) in the ephedrine and phenylephrine groups respectively (P = 0.41). Non-reassuring fetal heart trace was the only factor significantly associated with lower umbilical artery pH on multivariable regression analysis (β = −0.09, P = 0.002). Conclusions: We found no difference in neonatal umbilical artery pH between ephedrine and phenylephrine when used to treat spinal anesthesia induced hypotension during cesarean delivery in pre-eclamptic patients. Limitations of the study include its retrospective single center design and the fact that the choice of vasopressor was not randomized.

Local anaesthetic wound infiltration for postcaesarean section analgesia: A systematic review and meta-analysis.

BACKGROUNDWound infiltration with local anaesthetics has been investigated as a potentially useful method for providing analgesia after caesarean delivery, but the literature is inconclusive. OBJECTIVEThe objective is to assess the efficacy of local anaesthetic wound infiltration in reducing pain scores and opioid consumption in women undergoing caesarean delivery. DESIGNSystematic review of randomised controlled trials with meta-analyses. DATA SOURCESMEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled trials (CENTRAL) until December 2015. ELIGIBILITY CRITERIARandomised controlled trials that assessed the efficacy of local anaesthetic wound infiltration using an infusion or single injection technique for postcaesarean section analgesia. RESULTSA total of 21 studies were included in the final analysis (11 studies using an infusion technique and 10 studies using single infiltration). Local anaesthetic wound infiltration significantly decreased opioid consumption at 24 h [mean difference −9.69 mg morphine equivalents, 95% confidence interval (CI), −14.85 to −4.52] and pain scores after 24 h at rest (mean difference −0.36, 95% CI, −0.58 to −0.14) and on movement (mean difference −0.61, 95% CI, −1.19 to −0.03). Subgroup analysis did not suggest a difference in primary outcomes between infusions and single infiltration. Opioid consumption was reduced in patients who did not receive intrathecal morphine but not in those who received intrathecal morphine, although there were very little data in patients receiving intrathecal morphine. Pain scores at rest and on movement at 24 h were reduced with catheter placement below the fascia but not above the fascia. There were no statistically significant reductions in nausea, vomiting or pruritus with local anaesthetic infiltration. CONCLUSIONLocal anaesthetic wound infiltration reduces postoperative opioid consumption but had minimal effect on pain scores and did not reduce opioid-related side-effects in women who had undergone delivery by caesarean section. The review is limited by a paucity of studies using intrathecal morphine and by the indirect comparisons performed for subgroup analyses.

Antiemetics added to phenylephrine infusion during cesarean delivery: a randomized controlled trial.

OBJECTIVE: To estimate whether the addition of metoclopramide or its combination with ondansetron to a prophylactic phenylephrine infusion provides improved intraoperative nausea and vomiting prophylaxis compared with phenylephrine infusion alone. METHODS: Women scheduled for elective cesarean delivery were randomized to one of three groups: placebo (placebo plus placebo); metoclopramide (metoclopramide 10 mg plus placebo); or combination (metoclopramide 10 mg plus ondansetron 4 mg). The first study drug was administered before spinal placement and the second was administered after cord clamping. Spinal anesthesia was standardized. The primary outcome was intraoperative nausea and vomiting. RESULTS: Three-hundred patients completed the study in two centers. Intraoperative nausea and vomiting occurred in 49%, 31%, and 23% of patients in the placebo, metoclopramide, and combination groups, respectively (P<.001). There was a significant difference between the two centers in exteriorization of the uterus (93% compared with 39%; P<.001) and intraoperative nausea and vomiting rates (47% compared with 20%; P<.001). In a multivariable model adjusting for center, exteriorization of the uterus, age, and hypotension, intraoperative nausea and vomiting were significantly lower in the metoclopramide and combination groups compared with placebo (odds ratio [OR] 2.34, 95% confidence interval [CI] 1.24--4.42; P=.001 and OR 4.06, 95% CI 2.06--7.97; P<.001, respectively). Postoperative nausea and vomiting were reduced with the combination compared with placebo at 2 hours (39% compared with 20%; P<.017), but not at 2–6 hours or at 6–24 hours. CONCLUSION: Metoclopramide with ondansetron reduced intraoperative nausea and vomiting and early postoperative nausea and vomiting compared with placebo. Metoclopramide alone also decreased intraoperative but not postoperative nausea and vomiting. Surgical factors contributed to a significant difference in intraoperative nausea and vomiting between the two centers. CLINICAL TRIAL REGISTRATION: NCT01216410, ClinicalTrials.gov, www.clinicaltrials.gov. LEVEL OF EVIDENCE: I

Peripartum management of two parturients with ornithine transcarbamylase deficiency.

Ornithine transcarbamylase deficiency is a rare X-linked disorder in which female carriers are usually heterozygous for the ornithine transcarbamylase deficiency gene. In pregnancy it has been associated with altered mental status, seizures, coma and death, especially in the postpartum period. We report the management of labor and delivery in two parturients with known ornithine transcarbamylase deficiency. Both patients were maintained on arginine, citrulline and sodium phenylacetate therapy with restricted protein intake during pregnancy. Neuraxial techniques were used for pain relief in labor and anesthesia for operative delivery. A dextrose infusion provided caloric intake during labor and perioperatively.

The effect of a single intraoperative dose of intravenous dexamethasone 8 mg on post-cesarean delivery analgesia: a randomized controlled trial

BACKGROUND A single perioperative dose of dexamethasone has been shown to improve postoperative analgesia and reduce opioid consumption. However, this analgesic and opioid sparing effect has not been well assessed as part of a multimodal analgesic regimen in women post-cesarean delivery. METHODS Healthy women having cesarean delivery under spinal anesthesia were randomly assigned to receive intravenous dexamethasone 8 mg or placebo after delivery and clamping of the umbilical cord. The primary outcome variable was total opioid consumption in the 24 hours following cesarean delivery. We hypothesized that a single dose of intravenous dexamethasone, administered as part of a multimodal analgesia regimen after spinal anesthesia for cesarean delivery, would significantly reduce postoperative opioid consumption. RESULTS Fifty-two women were enrolled and randomized to two groups of 26 patients. The median (IQR) opioid consumption in the first 24 hours after cesarean delivery was 12 mg (5-20 mg) in the dexamethasone group compared to 15 mg (5-22 mg) in the placebo group. The median difference in opioid consumption at 24 hours (95% CI) was -3 mg (-12.2 to 5.7) and was not significantly different between groups (P=0.32). CONCLUSIONS The addition of intravenous dexamethasone 8 mg to a multimodal postoperative analgesic regimen that included intrathecal morphine, in women who had a cesarean delivery under spinal anesthesia, did not reduce 24 hour postoperative opioid consumption.

Use of hyperbaric oxygen therapy and PEGylated carboxyhemoglobin bovine in a Jehovah’s Witness with life-threatening anemia following postpartum hemorrhage

We present a case of a Jehovahs Witness patient who refused blood products, with the exception of albumin and clotting factors, and underwent cesarean section under spinal anesthesia complicated by postpartum hemorrhage. She was fluid resuscitated and treated with multiple uterotonics and internal iliac artery embolization. Because of agitation she required emergency tracheal intubation. Her hemoglobin concentration dropped from a preoperative value of 12mg/dL to 3mg/dL on postoperative day one. She was acidotic, requiring vasopressors for hemodynamic stability and remained ventilated and sedated. She was treated with daily erythropoietin, iron therapy and cyanocobalamin. Because of ongoing hemorrhage, continued acidemia and vasopressor requirements she was co-treated with PEGylated carboxyhemoglobin bovine and hyperbaric oxygen therapy to reverse her oxygen debt. On postoperative day eight her hemoglobin concentration was 7mg/dL, she was hemodynamically stable and vasopressors were discontinued. She was extubated and discharged from the intensive care unit on postoperative day eight. This report highlights the multiple modalities used in treating a severely anemic patient who refused blood, the use of an investigational new drug, the process of obtaining this drug via the United States Food and Drug Administration emergency expanded access regulation for single patient clinical treatment, and ethical dilemmas faced during treatment.