Retrospective analysis of anesthetic interventions for obese patients undergoing elective cesarean delivery

Study ObjectiveTo examine the relationship between body mass index (BMI), perioperative times, and anesthetic interventions in patients undergoing elective cesarean delivery.DesignRetrospective chart review.SettingUniversity-affiliated hospital.MeasurementsAll patients were ranked according to BMI (kg/m²) at the time of delivery. The BMI groups were designated a priori: ≤ 29.9 kg/m² (Group C); 30-34.9 kg/m² (Group I); 35-39.9 kg/m² (Group II), and ≥ 40 kg/m² (Group III). One hundred patients (25 pts per group) underwent elective cesarean delivery. Data collected included anesthetic technique, perioperative times, anesthesia-related costs, and neonatal outcomes.Main ResultsA higher percentage of Group III patients (60%) received combined spinal-epidural (CSE) anesthesia than did Group C or Group I (18% and 16%, respectively; P < 0.05). The total intraoperative period was significantly longer in Group III (101 min) compared with Groups C, I, and II (81 min, 90 min, and 92 min, respectively; P < 0.05). Total intraoperative time increased significantly with BMI (R = 0.394 kg/m²; P < 0.001). The highest anesthesia-related costs during the study were generated by patients with BMI ≥ 40 kg/m².ConclusionOur single-center experience showed that choice of anesthetic technique (CSE vs. spinal anesthesia) varies according to obesity class. Longer intraoperative periods must be considered in deciding upon the mode of anesthesia for patients with BMI ≥ 40 kg/m² who undergo elective cesarean delivery.     

Low-dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery

BACKGROUND AND OBJECTIVES: The hypotension following spinal anesthesia remains commonplace in cesarean delivery. Intrathecal opioids are synergistic with local anesthetics and intensify sensory block without increasing sympathetic block. The combination makes it possible to achieve spinal anesthesia with otherwise inadequate doses of local anesthetic. We hypothesized that this phenomenon could be used to provide spinal anesthesia for cesarean delivery while incurring less frequent hypotension. METHODS: Thirty-two women scheduled for cesarean delivery were divided into 2 groups of patients who received a spinal injection of either 10 mg of isobaric (plain) bupivacaine 0.5% or 5 mg of isobaric bupivacaine with 25 microg fentanyl added. Each measurement of a systolic blood pressure less than 95 mm Hg or a decrease in systolic pressure of greater than 25% from baseline was considered as hypotension and treated with a bolus of 5 to 10 mg of intravenous ephedrine. RESULTS: Spinal block provided surgical anesthesia in all patients. Peak sensory level was higher (T3 v T4. 5) and motor block more intense in the plain bupivacaine group. The plain bupivacaine patients were more likely to require treatment for hypotension (94% v 31%) and had more persistent hypotension (4.8 v 0.6 hypotensive measurements per patient) than patients in the minidose bupivacaine-fentanyl group. Mean ephedrine requirements were 23.8 mg and 2.8 mg, respectively, for the 2 groups. Patients in the plain bupivacaine group also complained of nausea more frequently than patients in the minidose bupivacaine-fentanyl group (69% v 31%). CONCLUSIONS: Bupivacaine 5 mg + fentanyl 25 microg provided spinal anesthesia for cesarean delivery with less hypotension, vasopressor requirements, and nausea than spinal anesthesia with 10 mg bupivacaine.     

200例剖宫产患者麻醉期间护理的分析

目的 探讨剖宫产术后患者麻醉期间的护理方法,完善促进母婴健康的产科护理模式.方法 选取2007年～2008年我院收治的血压、脉搏、呼吸、体温均正常的需行剖宫产术的产妇200例,按完全随机法分两组,对照组(n=100)接受常规护理,观察组(n=100)在对照组的护理基础上,根据剖宫产术麻醉手术的特点,有针对性地运用麻醉护理配合.两组患者入手术室后进行体征监护及相关项目的观察及记录,进行对比研究,旨在反映观察组产妇的护理效果.结果 观察组产妇的手术时间缩短[(24±6)min vs(18±3)min],术中出血、疼痛、新生儿窒息等明显低于对照组,患者满意度高于对照组(99%vs 85%)(P＜0.05).结论 对剖宫产产妇术中实施麻醉护理增进产妇舒适度和满意度,减少副作用的发生,保证手术顺利进行.     

The choice of elective cesarean delivery in obstetrics: a voluntary survey of Canadian health care professionals

To survey Canadian health care professionals about their willingness to offer elective cesarean delivery and to evaluate how their knowledge of obstetric-related pelvic-floor injury influences their practice. A voluntary questionnaire was distributed to health care professionals attending the 58th Annual Meeting of the Society of Obstetricians and Gynaecologists of Canada in 2002. Appropriate statistical analysis was used. One hundred and sixty-two questionnaires were completed. One hundred respondents were female (62%). Twenty-three percent (37/162) of respondents approved elective cesarean delivery after informed request in nulliparous women without an obstetrical indication. Males were more likely than females to perform cesarean delivery in these circumstances (34% versus 16%; OR 2.7, CI 1.2, 6.0). When questioned about the impact of mode of delivery on bladder and bowel continence, the number of respondents who answered usually or always has a detrimental effect were: vaginal birth, 16%; forceps, 20%; and cesarean delivery reduces bladder and bowel problems, 44%. Males were more likely to emphasize a protective effect of cesarean delivery (55% versus 38%; OR 1.9, CI 1.0, 4.0). Health care professionals would opt for cesarean delivery for themselves when forceps delivery was the alternative more often than they would offer cesarean delivery to their patients (OR 1.98, CI 1.1, 3.5). While a significant number of womens health care professionals are prepared to offer cesarean delivery to nulliparous women, informed choice seems to motivate the offer rather than a conviction that cesarean delivery will protect the pelvic floor.     

Perioperative analgesia with subarachnoid fentanyl-bupivacaine for cesarean delivery

Addition of fentanyl to bupivacaine administered for spinal anesthesia for cesarean delivery was evaluated in 56 ASA physical status 1 term parturients. Preservative-free saline was added to 0, 2.5, 5, 6.25, 12.5, 25, 37.5, or 50 micrograms fentanyl to make a 1 ml total volume, which was injected intrathecally prior to bupivacaine in a double-blind, randomized fashion. Vital signs, sensory level, motor block, pain score, and side effects were recorded every 2 min for the first 12 min and then at 15, 30, 45, and 60 min and at 30-min intervals until the patient complained of pain. At delivery maternal vein, umbilical artery, and umbilical vein blood gases were obtained. Apgar scores at 1 and 5 min were recorded. Early Neonatal Neurobehavioral Scales (ENNS) were performed on days 1 and 2. Side effects and opioid requirements were recorded for the first 24 h. All of the patients in the control group reported a pain score greater than 0 during surgery and 67% required intraoperative opioids. None of the patients who received greater than or equal to 6.25 micrograms fentanyl required intraoperative opioids. Complete analgesia (time from injection to first report of pain) lasted 33.7 +/- 30.8 min (mean +/- SD) in the control group and increased to 130 +/- 30 min (P less than 0.05) with addition of 6.25 micrograms fentanyl. Duration of effective analgesia (time from injection to first parenteral opioid) was 71.8 +/- 43.2 min in the control group and increased (P less than 0.05) to 192 +/- 74.9 min with addition of 6.25 micrograms fentanyl.(ABSTRACT TRUNCATED AT 250 WORDS)     

Nalmefene or naloxone for preventing intrathecal opioid mediated side effects in cesarean delivery patients

This study was designed to evaluate the efficacy of nalmefene vs. naloxone in preventing side effects resulting from intrathecal opioids, in patients undergoing cesarean delivery. Eighty patients who were scheduled for elective cesarean delivery under spinal anesthesia were included in a double-blind, placebo-controlled study. Patients were randomized into four groups: saline; intravenous nalmefene 0.25 micro.kg(-1) every 12 h x 2; intravenous nalmefene 0.5 microg.kg(-1) every 12 h x 2; and naloxone infusion 48 microg.h(-1) (1.2 microg.ml(-1)). There were no significant differences among the groups with respect to pain, sedation, satisfaction, or the occurrence or treatment of pruritus or nausea. There was a significant difference among the groups with respect to the occurrence of vomiting (P < 0.03): both nalmefene groups had a higher rate of vomiting than did the control group; the 0.25 microg.kg(-1) nalmefene group had a higher rate than did the naloxone group. The use of narcotic antagonists does not result in improved comfort in obstetrical patients receiving intrathecal morphine and fentanyl.     

Persistent pain after cesarean delivery

The incidence of persistent pain after cesarean deliveries (CD) varies but is much lower than after comparable surgeries. However, with over four million deliveries annually and a rising CD rate, even a low prevalence of persistent pain after CD impacts many otherwise healthy young women. Consideration of the pathophysiology of persistent pain after surgery and the risk factors predisposing women to persistent and chronic pain after CD provides insights into the prevention and treatment of persistent pain; and improves the quality of care and recovery after CD. The findings that the peripartum state and oxytocin confer protection against persistent pain may provide new and interesting perspectives for the prevention and treatment of chronic pain caused by trauma or surgery.Predictive tools available to identify and target patients at high risk of acute and chronic pain have mostly weak to modest predictive correlations and many are either not clinically feasible or too time-consuming to apply. Persistent pain has been linked to the severity of acute postoperative pain and opioid exposure. Modified surgical techniques, neuraxial anesthesia and opioid-sparing analgesia may help limit the development of persistent and chronic pain. The goal of this narrative review is to examine the incidence of persistent pain after CD; review briefly the underlying pathophysiology of persistent pain and the transition from acute to chronic pain (with particular emphasis on the uniqueness after CD); and to review modifiable risk factors and prevention strategies that identify at-risk patients and allow tailored treatment.     

The anesthetic management for cesarean delivery in a patient with Shone's syndrome

Shone's syndrome is a rare congenital cardiac condition that consists of up to four obstructive left-sided cardiac lesions. We report a 17-yr-old nullipara with Shone's syndrome who presented for cesarean delivery. She had mild mitral stenosis and mild left ventricular outflow tract obstruction. Epidural anesthesia was attempted, but the patient developed severe hypotension associated with fetal bradycardia necessitating immediate cesarean delivery under general anesthesia. The peripartum anesthetic and management considerations for these patients are discussed.     

Epidural lidocaine for cesarean delivery of the distressed fetus

Lidocaine with epinephrine and sodium bicarbonate has a rapid onset of action. We therefore wished to compare its use with that of chloroprocaine for urgent cesarean delivery. Thirty parturients for cesarean section under epidural anesthesia were divided into three groups. Group 1 required elective cesarean section and served as the control group for neonatal lidocaine levels. Groups 2 and 3 had been receiving epidural infusions of 0.125% bupivacaine with epinephrine 1:400,000 and required urgent cesarean section. They were randomized to receive either 1.5% lidocaine with epinephrine or 3% chloroprocaine, both with sodium bicarbonate 2 ml in a total volume of 25 ml. All patients had adequate anesthesia and none required supplementation. The time from completion of injection to the achievement of a T4 sensory level was significantly shorter in the chloroprocaine group (3.1 vs. 4.4 min). There were no differences in Apgar scores or Neurologic and Adaptive Capacity Scores between the lidocaine and chloroprocaine groups. Lidocaine was detectable in maternal serum from four of the urgent cases and all of the elective cases. It was detectable in five neonates from the elective group but none from the emergency group. In parturients with preexisting epidural catheters and a baseline epidural infusion to maintain a T10 sensory level, chloroprocaine is faster in onset than lidocaine, but the difference in this study was only 1.3 min, and both agents provided excellent anesthesia.     

The incidence of herpes simplex virus labialis after cesarean delivery

Epidural and subarachnoid opioids have been associated with the development of oral herpes simplex lesions. Because of this risk, some anesthesiologists avoid neuraxial morphine in parturients with a history of herpes simplex virus labialis. When we began using neuraxial opioids for analgesia after cesarean delivery, we did not see any increased incidence of facial lesions. To confirm this impression, we studied 357 consecutive parturients presenting for elective or emergent cesarean delivery between 1 December 1989 and 27 June 1990. The women received spinal, epidural, or general anesthesia. Two hundred and one women received either spinal or epidural morphine, the remaining 156 parturients received only systemic opioids for postoperative analgesia. An investigator saw each patient daily until discharge. Only 11 patients (3%) developed oral lesions while hospitalized. None of these women had severe lesions. Neuraxial morphine did not increase the risk of labial lesions significantly (3.5% vs. 2.6%). Despite published data to the contrary, we found no correlation between neuraxial morphine and the risk of facial herpes virus lesions in women after cesarean delivery. We offer patients the option of neuraxial morphine for analgesia after cesarean delivery despite any history of oral herpes lesions.