Concentration of lidocaine hydrochloride in newborn gastric fluid after elective caesarean section and vaginal delivery with epidural analgesia

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Comparison of epidural and intravenous opioid analgesia after elective caesarean section.

Patient acceptance is a particularly relevant method of assessing currently employed epidural and intravenous techniques of opioid analgesia after elective caesarean section. We have prospectively studied 71 such patients, randomised postoperatively to receive epidural morphine, intravenous morphine or intravenous pethidine. When compared with either intravenous opioid, epidural morphine provided twofold better average or excellent analgesia with 30% less drowsiness but with about 50% more pruritus. In spite of this troublesome complication, more patients (83% vs 74%) preferred epidural to intravenous opioid analgesia.     

High-dose diclofenac for postoperative analgesia after elective caesarean section in regional anaesthesia

Although the use of non-steroidal anti-inflammatory drugs (NSAIDs) is well established in the postoperative setting, their use after caesarean sections is still controversial. In a randomised, double-blinded, placebo controlled study we have estimated the opioid-sparing effect of diclofenac suppositories after elective caesarean sections in spinal anaesthesia. Eighty-two women ASA class I or II scheduled for caesarean section were randomised to receive either diclofenac suppositories 100 mg or placebo every 12 h after the operation. The diclofenac group (n = 40) consumed significantly less morphine in the postoperative period (14.0 +/- 1.5 mg in 32 h) compared with the placebo group (21.5 +/- 1.6 mg in 32 h, P < 0.05). The average level of postoperative pain as estimated by a visual analogue scale (VAS) and a verbal scale tended to be lower in the diclofenac group, but this was not significant. There were no differences in demographic data, perioperative bleeding, side-effects or discharge time between the groups. Diclofenac suppositories 100 mg given twice daily after caesarean section are opioid sparing.     

Fetal heart rate after epidural lidocaine and bupivacaine for elective cesarean section

This prospective double-blind study was designed to determine whether the fetal heart rate (FHR) changes that have been reported after epidural administration of bupivacaine and lidocaine during labor are present when larger doses of these drugs are given during elective cesarean section. Prior to inserting an epidural catheter, FHR and maternal vital signs were monitored during a control period in 60 healthy term parturients. Patients were randomly assigned to receive either 0.5% bupivacaine with 0.1 mEq sodium bicarbonate added to each 20 ml (n = 30) or 2% lidocaine with 1:300,000 epinephrine (n = 30). A 3-ml test dose of the study solution was injected via the catheter and was followed by an additional 17 ml, in increments; additional doses were administered as necessary to obtain surgical anesthesia. FHR and maternal vital signs were monitored for at least 20 min and the characteristics of the anesthetic block noted. At delivery, neonatal status was evaluated, and maternal and cord blood samples were obtained for local anesthetic assays and neonatal blood gases. The groups were similar with respect to maternal characteristics, onset of surgical anesthesia, time to delivery, and uterine incision-delivery interval. Maternal blood pressure decreased from control values in both groups (P less than 0.05), but there was no difference between the groups in either the incidence of hypotension or ephedrine requirements. Analysis of FHR tracings by a perinatologist blinded to the study group revealed no changes after anesthesia and no significant differences between the groups at any time in basal FHR, short- or long-term variability, or the incidence of accelerations or decelerations.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of epidural methadone with epidural diamorphine for analgesia following caesarean section

Analgesia provided by either 5 mg diamorphine, or 5 mg methadone administered by the epidural route during elective caesarean section was compared in 40 women. The median time to further analgesia in the methadone group was 395 min, and 720 min in the diamorphine group, P = 0.0003. Linear analogue scores to assess pain were measured 2-hourly for 12 h, then again at 24 h postoperatively. Pain scores were significantly lower in the diamorphine group at 8 and 10 h. The median cumulative i.m. morphine dose administered during the first 24 h was 20 mg in the methadone group and 0 mg in the diamorphine group (P = 0.0005). Nausea and pruritis were common side effects in both groups. Continuous pulse oximetry data were available for 12 h post-operatively in 15 patients receiving methadone, and in 17 patients receiving diamorphine. One or more episodes of significant desaturation (<90% for 30 s), occurred in three patients receiving methadone, and in nine patients receiving diamorphine. Desaturation to 90–92% occurred in a further three patients given epidural diamorphine, and in one further patient given epidural methadone.     

Dose response study of subarachnoid diamorphine for analgesia after elective caesarean section

Subarachnoid diamorphine provides excellent analgesia after elective caesarean section but the optimum dose is still uncertain. We therefore investigated the effects of three regimens of subarachnoid diamorphine. Forty parturients were assigned to one of four groups. A control group received no diamorphine in their subarachnoid bupivacaine and three study groups received 0.1 mg, 0.2 mg or 0.3 mg diamorphine added to 12.5 mg hyperbaric bupivacaine 0.5% in a semi-blind randomised design study. All women received a 100 mg diclofenac suppository at the end of the caesarean section and were provided with morphine patient controlled analgesia (PCA) postoperatively. The patients were assessed for pain, morphine usage and side-effects at 2, 4, 8 and 24 h after the subarachnoid injection. Postoperative visual analogue scores for pain and PCA morphine consumption were significantly lower, and mean time to first use of morphine was significantly longer in the 0.3 mg diamorphine group. The mean (SD) dose of PCA morphine used over 24 h was 39.4 (14.7), 25.6 (16.5), 21.6 (15.9) and 3.1 (3.6) mg, and mean time to first use of morphine was 1.6 (0.5), 3.0 (1.4), 3.4 (2.4) and 14.1 (9.4) h, in the 0, 0.1 mg, 0.2 mg and 0.3 mg groups respectively. Side-effects of pruritus, nausea and vomiting were dependent on the dose of spinal diamorphine but did not require treatment in any patients. We conclude that 0.3 mg subarachnoid diamorphine provides significantly better postoperative pain relief than the smaller doses with an acceptable increase in side-effects.     

Patient-controlled analgesia: epidural fentanyl and i.v. morphine compared after caesarean section

We have compared patient-controlled epidural fentanyl (PCEF) and patient-controlled i.v. morphine (PCIM) after Caesarean section in 84 patients, in a randomized, double-blind study. All patients had an epidural and an i.v. patient-controlled analgesia (PCA) device, one of which delivered normal saline. Group PCEF received epidural fentanyl 20 micrograms with a 10-min lockout. Group PCIM received i.v. morphine 1 mg with a 5-min lockout. PCA use was lower for PCEF patients (P = 0.0007). The highest pain score recorded at rest for PCEF patients was median 20 (interquartile range 10-33) mm compared with 32 (14-52) mm for PCIM patients (P = 0.02). The highest pain score recorded on coughing was 31 (21-41) mm with PCEF compared with 56 (30-71) mm for PCIM (P = 0.001). There was less nausea (P = 0.02) and drowsiness (P = 0.0003) with PCEF. There was no difference in the overall incidence and severity of pruritus (P = 0.77). However, pruritus started earlier with PCEF.      

经硬膜外穿刺针注入利多卡因对剖宫产术连续硬膜外麻醉效应的影响

目的评价经硬膜外穿刺针注射局麻药后再置管对剖宫产术连续硬膜外麻醉效应的影响。方法单胎足月妊娠拟在连续硬膜外麻醉下行子宫下段剖宫产术的产妇100例,ASAⅠ或Ⅱ级,随机均分为研究组（P组）和对照组（C组）。硬膜外穿刺成功后,P组先通过硬膜外针注入2%利多卡因,注射完后保持注射器压缩针栓20 s,使液体充分扩散后再置入硬膜外导管;C组置入硬膜外导管后再注入2%利多卡因。记录置入硬膜外导管时的不良反应;测量给药完毕后20 min的麻醉平面,并评估麻醉满意度;记录置管时主诉异感和发生单侧阻滞的例数。结果与C组比较,P组硬膜外穿刺针针尾见淡红色血水的发生率（14%vs.36%）、硬膜外导管回抽出淡红色血水的发生率（4%vs.16%）明显降低（P<0.05）。P组利多卡因用量为（312±18）mg,明显少于C组的（355±32）mg（P<0.01）。给药后20 minP组的麻醉平面达T_5.6±0.8,明显高于C组的T_6.5±1.1（P<0.01）,且麻醉满意度显著增加（96%vs.84%）（P<0.01）。结论硬膜外置管前从硬膜外针注入局麻药不仅能有效减少置管对剖宫产产妇硬膜外血管的损伤,而且还能显著提高麻醉效果,减少局麻药的用量。     

Cough reflex sensitivity after elective Caesarean section under spinal anaesthesia and after vaginal delivery

BACKGROUND: In pregnancy, airway oedema and heartburn may increase cough sensitivity, whereas spinal anaesthesia (SA) with local anaesthetics and opiates may decrease it. Decreased cough sensitivity increases the risk for pneumonia or retained secretions. The aim of this study was to determine whether cough sensitivity is increased in pregnant patients and if it is decreased after planned Caesarean section (CS) under SA. METHODS: Twenty-seven non-pregnant volunteers, 27 patients after vaginal delivery (VD group), and 28 patients after CS under SA (CS group) were studied. For SA, hyperbaric bupivacaine 8-12 mg, sufentanil 5 microg, and morphine 100 microg was given. Increasing concentrations of nebulized citric acid were delivered until eliciting cough. The concentration eliciting one (C1) and two coughs (C2) were recorded and log transformed for analysis (log C1 and log C2). RESULTS: Median (inter-quartile) log C1 was 1.3 (0.6) mg ml(-1) in the VD group, 1.6 (0.6) mg ml(-1) in the non-pregnant group (P < 0.01 vs VD group), and 2.2 (0.7) mg ml(-1) in the CS group (P < 0.0001 and P < 0.01 vs VD and non-pregnant groups, respectively). Similar results were observed with log C2. In CS group, log C1 and log C2 remained increased up to 4 h after SA. CONCLUSIONS: Cough sensitivity was increased after VD but decreased for up to 4 h after SA.     

A comparison of patient controlled epidural pethidine versus single dose epidural morphine for analgesia after caesarean section

This double-blind, randomized study of analgesia after caesarean section compared patient controlled epidural analgesia with pethidine (15 mg of a 0.25% solution and a 10 minute lockout period) versus a single bolus of epidural morphine 4 mg. Data were collected on 78 patients at 2, 6, 8, and 24 hours postoperatively and analysed using the Wilcoxon rank sum test. Satisfactory analgesia and nausea/vomiting during the first twenty-four hours did not differ between the two groups. The incidence of pruritus (P < 0.001) was lower in the pethidine group at 2, 6, and 8 hours, with no difference by 24 hours. Therefore PCEA pethidine provides a useful alternative to single-dose morphine after caesarean section, particularly in those patients who have suffered severe morphine-induced pruritus previously.     

Central neuraxial opioid analgesia after caesarean section: comparison of epidural diamorphine and intrathecal morphine

In a prospective, randomized, double-blind study in 55 women undergoing elective caesarean section under spinal anaesthesia, we compared epidural diamorphine 3 mg (2 distinct boluses, group ED) with single-dose intrathecal morphine 0.2 mg (group SM), in terms of analgesic efficacy, patient satisfaction and side-effects at 2, 3, 4, 8, 12, 16, 24 and 28 h postoperatively. There were no significant differences between groups in pain (assessed by 100 mm visual analogue scale), incidence of pruritus, sedation or respiratory depression measured by continuous pulse oximetry. However, time to first request for supplementary oral analgesia was longer in SM than in ED (mean +/- SD: 22.3+/-12.0 h vs. 13.8+/-6.5 h, P=0.04). The incidence of nausea or vomiting was significantly higher in SM than ED (73% vs. 41%, P=0.01). In ED, the mean +/- SD time to requirement of the second bolus was 6.7+/-3.2 h. There was a high level of satisfaction in both groups. We conclude that two boluses of epidural diamorphine 3 mg and single-dose intrathecal morphine 0.2 mg provide satisfactory analgesia after caesarean section, but spinal morphine was associated with both delayed requirement for supplementary analgesia and a higher incidence of nausea and vomiting.     

剖宫产术后硬膜外镇痛对产妇催乳素及新生儿神经行为的影响

目的 研究布托啡诺复合左布比卡因在剖宫产术后硬膜外镇痛对产妇泌乳及新生儿神经行为的影响.方法 选择剖宫产产妇60例,按术后镇痛方式不同分为3组(B、M、C组,每组20例),B组:0.006％布托啡诺+0.15％左布比卡因;M组:0.004％的吗啡+0.15％左布比卡因;C组:术后疼痛时采用盐酸哌替啶肌注镇痛(1 mg/kg).B、M组采用连续硬膜外镇痛.术后进行视觉模拟评分(VAS)并记录恶心、呕吐等副作用发生率,测产妇血清催乳素(prolactin,PRL)浓度并记录产后初乳时间,进行新生儿神经和适应能力评分(NACS).结果 B组[4 h:(1.1±0.7),8 h:(1.2±1.2),12 h:(1.7±1.1),24 h:(1.4±1.5),48 h:(1.0±0.9)]、M组[4 h:(1.1±0.9),8h:(1.3±1.9),12 h:(1.6±1.2),24 h:(1.3±1.3),48 h:(1.0±0.7)]的VAS评分明显低于C组[4 h:(2.2±1.3),8 h:(4.3±1.7),12 h:(4.7±1.5),24 h:(3.6±1.3),48 h:(2.4±1.1)](P＜0.05),但M组恶心呕吐(30％)、瘙痒(25％)等副作用要明显高于B组(分别为:3％,0％)(P＜0.05),B组(26±8)h、M组(26±9)h泌乳时间要早于C组(35±10) h(P＜0.05),且B组[分别为:(357±62)、(387±63) μg/L]、M组[分别为:(367±64)、(392±61) μg/L]术后24、48 h PRL明显高于术前[B组:(220±59) μg/L,M组:(238±70) μg/L]及C组[分别为:(299±93)、(327±74)ug/L],而B、M差异无统计学意义,3组NACS比较无统计学意义.结论 布托啡诺复合左布比卡因用于剖宫产术后硬膜外镇痛效果好、副作用少且可促进产妇泌乳,对新生儿神经行为无明显影响.     

Combined spinal epidural anaesthesia for elective caesarean section in a patient with spondylometaphyseal dysplasia

A patient with spondylometaphyseal dysplasia, an extremely rare form of dwarfism, presented for elective caesarean section. We report the successful management under regional anaesthesia, using a combined spinal epidural technique. There seem to be only two previous reports of spinal anaesthesia and there are no previous reports of the use of combined spinal epidural in a pregnant dwarf. Regional anaesthesia is thought to be complex in these dwarfs due to vertebral malformation and unpredictable anatomy of the spinal canal. They may present difficulties with intubation as well. Spondylometaphyseal dysplasia is reviewed and its anaesthetic implications discussed.     

Comparison of lidocaine CO2, two per cent lidocaine hydrochloride and pH adjusted lidoaine hydrochloride for caesarean section anaesthesia

Lidocaine can be prepared in a variety of ways which may affect the characteristics of neural blockade achieved. Experimental evidence is equivocal as to the clinical impact of the use of different lidocaine preparations. A randomized, double-blind study was performed to investigate the differences in epidural anaesthesia for Caesarean section using three different lidocaine solutions: lidocaine CO2, two per cent lidocaine and two per cent lidocaine with its pH adjusted by the addition of bicarbonate. No differences were found among the groups in time of onset of neural blockade, quality or duration of neural blockade, time to delivery of the infant or volume of anaesthetic solution injected into the epidural space. A significant difference was found between the pH's of the solutions used. It is concluded that all three solutions are equally efficacious in epidural anaesthesia for Caesarean section.     

Pressure-sensitive neuropathy after obstetric delivery with epidural analgesia

We report the case of a woman who requested epidural analgesia for labor in whom catheterization of the epidural space was difficult, requiring multiple punctures; furthermore, the epidural block was followed by a long expulsion phase in the delivery room. Shortly after delivery the patient experienced paresthesia and weakness in her lower limbs. A diagnosis of pressure-sensitive, or tomaculous neuropathy was based on clinical observation and neurophysiologic and genetic studies. This hereditary disease, which affects peripheral nerve myelin, involves recurrent episodes of focal demyelination when nerves are injured slightly or compressed. This condition is probably underdiagnosed, as there are very few references to it in the literature on anesthesia.     

Incisional and epidural analgesia after caesarean delivery: a prospective, placebo-controlled, randomised clinical study

BACKGROUND: This study evaluated efficacy, safety and patient satisfaction with incisional analgesia with a subfascial catheter compared to epidural analgesia for pain relief following caesarean section. METHODS: Forty patients were randomised after elective caesarean section to receive either intermittent 10-mL boluses of 0.125% levobupivacaine into the epidural space and physiologic saline into the surgical wound or intermittent 10-mL boluses of 0.25% levobupivacaine into the wound and epidural saline with a repeated 10-dose regimen. Analgesic efficacy was evaluated by numerical pain scores (0-10, 0=no pain, 10=worst pain) and based on the consumption of supplemental opioid. Side effects, patient satisfaction and plasma concentrations of levobupivacaine were recorded. RESULTS: In the epidural group average pain scores were lower (1.8 vs. 3, P=0.006) and the consumption of local anaesthetic (29 mL vs. 38 mL, P=0.01) was smaller during the first four postoperative hours, after which both groups had pain scores of 3 or less at rest. All parturients were able to walk after the 24-h study period. The total consumption of rescue opioid oxycodone (32 vs. 37 mg, P=0.6) during the whole 72-h study period was low in both study groups. Side effects were mild and rare. Satisfaction scores were equally high in the two groups. Peak plasma concentrations of levobupivacaine were below the toxic range. CONCLUSION: Incisional local analgesia via a subfascial catheter provided satisfactory pain relief with patient satisfaction comparable to that seen with epidural analgesia. This technique may be a good alternative to the more invasive epidural technique following caesarean section as a component of multimodal pain management.