Yaakov Beilin

Quality of analgesia when air versus saline is used for identification of the epidural space in the parturient.

Background and Objectives Identification of the epidural space is often performed using the loss-of-resistance technique (LOR), commonly with air or saline. The effect of air or saline on the quality of labor epidural analgesia has not been adequately studied. Methods Women who requested labor epidural analgesia were randomly assigned to 1 of 2 groups depending on the syringe contents used for the LOR technique and injected into the epidural space. In the air group (n = 80) the anesthesiologist used 2 mL of air, and in the saline group (n = 80) the anesthesiologist used 2 mL of 0.9% saline. After LOR was obtained, a multiorifice epidural catheter was threaded 5 cm into the epidural space and 13 mL of bupivacaine 0.25% was administered in divided doses. The success of the epidural block was determined by asking the patient if she required additional medication 15 minutes later. The occurrence of paresthesias and intravascular or subarachnoid catheters was noted. Results In the air group, 36% of patients requested additional pain medication, and in the saline group 19% requested additional medication (P = .022). We were not able to find a statistically significant difference between groups in the incidence of paresthesias (42% air v 51% saline), intravascular catheters (5% air v 8% saline), or subarachnoid catheters (0 in both groups). Conclusions Using 0.9% saline for the LOR technique is associated with better analgesia as compared with air for labor analgesia, and this advantage should be considered when selecting the syringe contents for the LOR technique.

The use of propofol, nitrous oxide, or isoflurane does not affect the reproductive success rate following gamete intrafallopian transfer (GIFT) - A multicenter pilot trial/survey

BACKGROUNDnWhether anesthetic agents administered during gamete intrafallopian transfer (GIFT) affect reproductive outcome is controversial. This multicenter pilot trial and survey had two purposes: to evaluate the effect of propofol, nitrous oxide, midazolam, and isoflurane on pregnancy outcome after GIFT, and to determine if a larger prospective, randomized study is warranted.nnnMETHODSnA written invitation was mailed to all 50 fertility programs in the United States that are members of the Society for Assisted Reproductive Technology and perform more than 30 GIFT procedures per year. They were invited to contribute information from the medical records of women who underwent GIFT during the calendar years 1993 and 1994. They were asked to document whether propofol, nitrous oxide, midazolam, a potent inhaled anesthetic agent was used during the GIFT procedure; if the woman became pregnant; and if she delivered at least one live neonate.nnnRESULTSnSeven medical centers participated and contributed data from 455 women. The clinical pregnancy rate (number of pregnancies/total number of GIFT procedures) and the delivery rate (number of women who delivered at least one live baby/total number of GIFT procedures) were 35% and 32%, respectively. A statistically significant difference could not be found in the clinical pregnancy or delivery rates between those women who received propofol, nitrous oxide, midazolam, or isoflurane during GIFT and those who did not.nnnCONCLUSIONSnNo agent-related differences in pregnancy rates were found when propofol, nitrous oxide, isoflurane, or midazolam was used as part of the anesthetic technique for GIFT. Therefore, a more extensive prospective trial does not appear to be warranted.

Thrombocytopenia, low molecular weight heparin, and obstetric anesthesia

The parturient with coagulation defects, whether related to thrombocytopenia or to anticoagulation therapy, presents a unique challenge to the anesthesiologist. The risk of spinal or epidural hematoma in these patients has not been quantified fully but is a factor that one must consider on a case-by-case basis in determining whether neuraxial anesthesia is appropriate for the parturient. Following the guidelines set forth in this article should help reduce the risk of spinal or epidural hematoma without sacrificing the quality of care provided to patients.

Information and concerns about obstetric anesthesia: a survey of 320 obstetric patients.

This study was undertaken to assess womens knowledge and concerns about obstetric anesthesia and to determine if they perceive a need for an anesthesia interview before the onset of labor. A 17 item questionnaire was distributed to 407 women on postpartum day one. The women were questioned about their knowledge, anxiety and concerns regarding obstetric anesthesia. The questionnaire was completed by 320 women, 57% of whom were Caucasian and 28% of whom had some postgraduate education. Most of the women (74%) had either a regional or general anesthetic for their delivery and 86% of the women admitted to having some anxiety about anesthesia. Although 82% of the women attempted to obtain information about anesthesia before labor, 28% did not feel adequately informed. The majority (59%) of the women would have wanted a preoperative visit with an anesthesiologist before labor. These results illustrate that most women are anxious about obstetric anesthesia and do not feel adequately prepared. Efforts at educating women about obstetric anesthesia would be welcomed by them and methods to accomplish this goal are discussed.

Comparison of Non-invasive Blood Pressure Measurements on the Arm and Calf During Cesarean Delivery

Objective. Shivering may occur in 75% of women undergoing spinal anesthesia for cesarean delivery and may render an automated noninvasive blood pressure (ANIBP) device incapable of determining blood pressure (BP). When patients shiver under spinal anesthesia, the lower extremities do not exhibit the same involuntary muscle movements as do the upper extremities. This study was undertaken to determine if a correlation exists between ANIBP measurements in the arm and calf of women undergoing cesarean delivery under spinal anesthesia. Methods. We enrolled 73 women in this blinded, prospective study. Simultaneous arm and calf BP were measured with an ANIBP and differences between the two were determined. Results. We found significant differences between the average difference in systolic and in diastolic BP, no significant difference between the average mean BP, and a tendency for the systolic BP to be higher and the diastolic BP to be lower in the calf than in the arm; however, there was a large degree of variability among patients. Conclusion. We conclude that there is a poor correlation between the BP measured by an ANIBP on the calf and one on the arm. In the parturient undergoing cesarean section, lower extremity BP as measured by an ANIBP does not correlate with the arm ANIBP and should not be used to assure fetal wellbeing.

Improved epidural analgesia in the parturient in the 30° tilt position

Purpose: To compare the incidence of incomplete analgesia when epidural local anesthetic is administered with the parturient supine in a 30° leftward tilt or in the left lateral decubitus position.Methods: After placement of a multiorifice catheter 5 cm into the epidural space, 293 women in active labour were randomly positioned either to the left lateral decubitus position (lateral group) or supine with a 30° leftward tilt (tilt group) and then received 13 mL bupivacaine 0.25%. The success of the epidural block was determined by asking the patient if she required additional medication 15 min later. The incidence of complications (fetal heart rate decelerations, hypotension, and ephedrine usage) was noted.Results: In the lateral group, 38% required additional medication compared with 24% in the tilt group (P=0.006). There were no differences between groups in the incidence of maternal hypotension or fetal heart rate decelerations, but more women (10%) received ephedrine in the lateral than in the tilt group (4%),P=0.035.Conclusions: Placing the parturient supine with a 30° leftward tilt is associated with a greater success rate of labour epidural analgesia without an increase in complications than in women in the left lateral decubitus position. This advantage should be considered when positioning the parturient after epidural catheter placement.RésuméObjectif: Comparer l’incidence d’analgésie incomplète lorsqu’un anesthésique local épidural est administré chez une parturiente installée en décubitus dorsal, inclinée à 30° vers la gauche, ou en décubitus latéral gauche.Méthode: Après la mise en place d’un cathéter à orifices multiples à 5 cm dans l’espace épidural, 293 femmes en travail actif ont été installées, en décubitus latéral gauche (groupe latéral), ou en décubitus dorsal avec une inclinaison de 30° vers la gauche (groupe incliné) et ont reçu 13 mL de bupivacaïne à 0,25 %. La réussite du blocage épidural a été établie en demandant aux patientes, 15 min plus tard, si l’analgésie était suffisante. L’incidence de complications (décélération de la fréquence cardiaque fœtale, hypotension et usage d’éphédrine) a été notée.Résultats: Dans le groupe latéral, 38 % des femmes ont demandé des médicaments supplémentaires en comparaison de 24 % dans le groupe incliné (P=0,006). Il n’y a pas eu de différence intergroupe quant à l’incidence d’hypotension maternelle ou de décélération de la fréquence cardiaque fœtale, mais davantage de femmes (10 %) ont reçu de l’éphédrine dans le groupe latéral, comparé au groupe incliné (4 %),P=0,035.Conclusion: L’installation d’une parturiente en décubitus dorsal, inclinée à 30° vers la gauche, comparée à la position de décubitus latéral gauche, est associée à un taux de succès plus élevé d’analgésie épidurale pendant le travail sans complications additionnelles. C’est un avantage à considérer quand on cherche une position appropriée pour une parturiente après la mise en place d’un cathéter épidural.

Thyroid and parathyroid surgery in pregnancy.

The consideration of surgery during pregnancy requires weighing the benefit of urgent surgery against the risk to mother and fetus. Surgery during pregnancy involves an increase in both maternal and fetal risks. Thyroid and parathyroid surgery involves physiological risks to both mother and fetus specific to the disease and function of these endocrine glands. Evaluation of a thyroid mass is similar in pregnant patients with ultrasound and fine-needle aspiration biopsy providing the most important information, while the use of radiographic imaging is severely constrained except when specifically required. In general, thyroid surgery can be delayed until after delivery except in cases of airway compromise or aggressive cancer. In contrast, parathyroid surgery is recommended during pregnancy to avoid adverse effects to the neonate.

A survey of anesthesiologists’ and nurses’ attitudes toward the implementation of an Anesthesia Information Management System on a labor and delivery floor

BACKGROUNDnAn anesthesia information management system (AIMS) is most frequently used in the operating room, but not on labor and delivery (L&D). The purpose of this study is to describe the implementation of an AIMS on L&D and the attitudes of practitioners (anesthesiologists and nurses) toward the system.nnnMETHODSnThe anesthesiology survey focused on satisfaction with the L&D AIMS, comparison of the L&D AIMS with a handwritten anesthesia record, and comparison of the L&D AIMS with the operating room AIMS. The nursing survey focused on nursing satisfaction with the L&D AIMS and comparison of the L&D AIMS with a handwritten anesthesia record.nnnRESULTSnMost anesthesiologists (76%) were satisfied with the L&D AIMS and 73% would not want to revert back to the paper record. However, most anesthesiologists felt the operating room AIMS was either superior or equal to the L&D AIMS. Although few nurses (4%) preferred the anesthesiologists revert back to the handwritten record overall, the nurses were neutral in their assessment of the AIMS. Most of the criticism related to the location of the system; 56% believed it was not in a convenient location and 74% thought the AIMS equipment got in their way.nnnCONCLUSIONSnOverall, the anesthesiologists and nurses are satisfied with the L&D AIMS and would not want to switch back to a handwritten record. We conclude that AIMS should not be limited to the operating room setting and can successfully be used in L&D.

Respiratory arrest in patients undergoing arteriovenous graft placement with supraclavicular brachial plexus block: a case series ☆,☆☆

Supraclavicular brachial plexus block is commonly used for upper extremity surgery. Respiratory arrest in three patients with end-stage renal disease after ultrasound-guided supraclavicular brachial plexus block for creation of an arteriovenous graft over a 6-month period is presented. Patients with renal failure may represent a group at particular risk for respiratory failure following supraclavicular brachial plexus block.

An ex utero intrapartum treatment procedure in a patient with a family history of malignant hyperthermia

In the EXIT (ex utero intrapartum treatment) procedure, after uterine incision, uterine relaxation is maintained to prevent placental separation and the fetus is supported via the placenta until the airway is successfully established. The traditional method to maintain uterine relaxation is with the use of high-dose potent inhaled anesthetics during general anesthesia. A patient with a family history of malignant hyperthermia required an EXIT procedure. The history of malignant hyperthermia precluded the use of potent inhaled anesthetics and an alternate plan using propofol and remifentanil infusions for anesthesia and nitroglycerin 16 μg/kg/min for uterine relaxation allowed for good surgical conditions. The presence of malignant hyperthermia required an alternate plan and close collaboration in order to ensure good patient outcome.