A randomized comparison of onset of anesthesia between spinal bupivacaine 5 mg with immediate epidural 2% lidocaine 5 mL and bupivacaine 10 mg for cesarean delivery

BackgroundPrevious studies using low-dose spinal anesthesia for cesarean delivery have focused on hypotension and efficacy. This study evaluated whether, using a combined spinal–epidural technique, there was a difference in onset of anesthesia for cesarean delivery between low-dose spinal with an immediate epidural local anesthetic bolus, and conventional-dose spinal anesthesia.MethodsForty healthy term nulliparous women undergoing elective cesarean delivery with a combined spinal–epidural technique were enrolled into this prospective, randomized, double-blind study. Patients were randomly allocated to the low-dose (Group L) or conventional-dose group (Group C). Patients in Group L received intrathecal isobaric bupivacaine 5 mg with sufentanil 2.5 μg followed by epidural 2% lidocaine 5 mL; patients in Group C received intrathecal isobaric bupivacaine 10 mg with sufentanil 2.5 μg followed by epidural saline 5 mL. The onset of anesthesia (defined as the time from spinal injection to a block to T6), incidence of hypotension, maximal sensory block, epidural supplementation and side effects were recorded.ResultsAll blocks reached T6 within 11 min except for one patient in Group L. There were no differences in onset of anesthesia (9.9 ± 3.2 min in Group L vs. 8.5 ± 1.2 min in Group C, P = 0.08), maximal block level and the number of patients who required epidural supplementation in both groups. Hypotension occurred in 8 patients (40%) in Group L and 15 patients (75%) in Group C (P = 0.02).ConclusionsIntrathecal bupivacaine 5 mg with immediate 2% epidural lidocaine 5 mL provided comparable onset and efficacy of anesthesia as bupivacaine 10 mg with immediate epidural normal saline 5 mL for cesarean delivery.     

Transplacental transfer and neonatal influences of sonophoretically administered sufentanil versus epidural sufentanil in labor peridural analgesia: A randomized prospective double-blind contemplate

BackgroundLabor sufentanil impact on the newborn is debatable. This randomized double-blind investigation examined the transplacental conveyance and neonatal influences of sonophoretic versus epidural sufentanil for labor analgesia and its outcome on breast-feeding.Methods60 Healthy parturient women receiving labor epidural analgesia were enrolled in the study. They were administered epidural bupivacaine (12-ml bolus then 10 ml/h of 0.125%) solely (Group I, n = 20) or with sonophoretically transdermally administered sufentanil (Group II, n = 20) or with epidurally administered sufentanil (Group III, n = 20). Sufentanil received by Groups II and III was 15 μm followed by 10 ml/h of 0.25 μm/ml solution.ResultsSufentanil was detected in five umbilical arterial (UA) samples in Group III versus in two UA samples in Group II. Neonatal Neurologic and Adaptive Capacity Score (NACS) at 24 h was lowest in Group III (P = 0.04). On postpartum day 1, Group III women reported breast-feeding difficultly (25%) more oftentimes than Group II women (10%), or Group I women (5%) (P = 0.05). There was 45% breast-feeding difficulty in each group according to lactation consultant’s assessment (P = 1.0). At 6 weeks postpartum, more Group III women were not breast-feeding (35%) than Group II women (10%) or Group I (10%) (P = 0.004).ConclusionSufentanil transplacental transport and fetal exposure appeared greater in epidural than in sonophoretic sufentanil. The former group women were facing more difficulty at starting breast-feeding on postpartum day 1 and were more apt to have stopped breast-feeding 6 weeks postpartum than the latter group women.     

The relationship between body mass index and post-dural puncture headache in obstetric patients

BackgroundDifficult epidural insertion and accidental dural puncture are more likely in the obese pregnant population. Low-level evidence suggests that the risk of post-dural puncture headache declines as body mass index increases.MethodsWe retrospectively reviewed prospective data on 18 315 obstetric epidural and combined spinal–epidural insertions, identifying 125 (0.7%) accidental dural punctures or post-dural puncture headaches between 2007 and 2012. The audit record and patient medical record were examined to determine patient body mass index, headache characteristics and use of a therapeutic epidural blood patch. Women were classified into two groups: non-obese (body mass index <30 kg/m², Group <30) or obese (body mass index ⩾30 kg/m², Group ⩾30). Statistical analysis was by chi-square or Fisher exact tests, with P < 0.05 considered significant.ResultsCompared to Group <30 (n = 65), women in Group ⩾30 (n = 60) did not significantly differ in the incidence of post-dural puncture headache (82% vs 80%, P = 0.83); its intensity (severe 36% vs. 23%, P = 0.34); or the need for epidural blood patch (57% vs. 54%, P = 0.81). Groups also did not differ significantly when confining analysis to those who had a witnessed accidental dural puncture (n = 93) or to women with a body mass index >40 kg/m² (n = 10) vs. Group <30.ConclusionThis retrospective study found no evidence that women of higher body mass index are less likely to develop a post-dural puncture headache or that the characteristics of the headache and use of epidural blood patch were different.     

Neuraxial opioids for post-cesarean delivery analgesia: can hydromorphone replace morphine? A retrospective study

BackgroundCesarean delivery is the most common surgical procedure performed in the USA. We evaluated the postoperative analgesic properties of neuraxial hydromorphone compared to neuraxial morphine for post-cesarean delivery analgesia.MethodsA retrospective chart review was performed of women who underwent cesarean delivery and received neuraxial anesthesia from March to November 2011 and from March to November 2012. A total of 450 patients received intrathecal morphine 200 μg and 387 patients received intrathecal hydromorphone 60 μg. Eighty-one patients received epidural morphine 3 mg and 102 patients received epidural hydromorphone 0.6 mg.ResultsMedian time to first opioid after intrathecal morphine was 17.0 h versus 14.6 h after intrathecal hydromorphone (P <0.0001). Patients who received intrathecal hydromorphone consumed more opioids in the first 24 h; 37.0 mg versus 26.4 mg oral morphine equivalents (P <0.001). The side effect profile between the intrathecal groups was similar. Median time to first opioid with epidural morphine was 20.1 h versus 13.0 h with epidural hydromorphone (P=0.0007). Total opioid consumption was not significantly different between the epidural groups. The side effect profiles were similar.ConclusionsHydromorphone is a reasonable alternative to morphine for post-cesarean delivery analgesia. With the dosing used in our study, analgesia from morphine lasted longer than hydromorphone via intrathecal and epidural routes; however, neuraxial hydromorphone remains a reasonable option for long-acting analgesia post cesarean delivery.     

Optimal epidural analgesia for patients diagnosed as having gynecologic cancer undergoing interstitial brachytherapy

Study objectiveTo determine the optimal epidural analgesia for patients receiving interstitial brachytherapy (ISBT) for gynecologic cancers.DesignRetrospective analysis.SettingOperating room and hospital ward.PatientsSeventy-three patients diagnosed as having gynecologic cancer and undergoing ISBT.InterventionsTwelve patients received ropivacaine alone, 14 patients received ropivacaine with fentanyl, and 45 patients received ropivacaine with hydromorphone by epidural infusion.MeasurementsNumeric Rating Scale pain scores, amounts of nonnarcotic and narcotic pain medications used in intravenous morphine equivalents (IVMEs), and amount of antiemetic or antipruritic medications used.Main resultsPatients receiving ropivacaine alone had higher pain scores the morning of day 2 (4.2 vs 1.71 vs 0.6, P = .001), the afternoon of day 2 (4.9 vs 2.5 vs 1.7, P = .005), and the night of day 2 (2.4 vs 2.0 vs 0.6, P < .001). Patients receiving opioids in their epidural had lower pain scores on the night of placement (P = .050), the morning of day 2 (P < .001), the afternoon of day 2 (P = .002), and the night of day 2 (P < .001). Patients receiving ropivacaine alone used more oral narcotics than did those receiving ropivacaine with fentanyl or ropivacaine with hydromorphone on day 3 (5.9 vs 3.8 vs 2.8 mg IVME) and received more intravenous opioids day 1 (5.8 vs 0.0 vs 0.7 mg IVME, P = .004) and day 2 (20.6 vs 4.8 vs 1.0 mg IVME, P = .042). There were no differences in antiemetic or diphenhydramine usage at any time point. No epidural complications occurred.ConclusionsFor patients receiving ISBT for gynecologic cancer, epidural analgesia provides safe and effective pain control. Combined modality epidural analgesia improves pain control and lessens oral and intravenous opioid requirements without increased risk of adverse effects compared with epidural analgesia with local anesthetic alone.     

Autoevaluación de una vía clínica para mejora del proceso quirúrgico carcinoma de recto

ObjectivesTo analyse whether the self-evaluation of a clinical pathway improves the results of rectal cancer (RC) treatment.Patients and methodPatients operated on for RC were divided into 3 groups according to biannual modifications of a clinical pathway analysing several indicators.Results166 patients: Group A: 2002 – 3 n=50, B: 2004 – 5 n=53 and C: 2006 – 7 n=63, without any differences in age, gender or comorbidity. Preoperative study improved with the introduction of CT scan: 76% in Group C vs. 6% in Group A (P<0.001). All Group C tumours were staged using MR, rectal ultrasound or both, compared to 84% in Group A (P<0.001). The rate of abdominal-perineal resections was reduced from 42% (Group A) to 17% (Group C); (P=0.007) and about 48% of surgeons in Group A vs. 94% in the C had a specific activity in coloproctology (P<0.001). The average lymph node count was: Group A=6.2±4.5 vs. 13±6.5 in the C and circumferential margin analysis was reported in 24% of Group A vs. 76% in Group C (P<0.001). Parameters such as perioperative blood transfusion, ICU admission, use of nasogastric tube, early feeding or epidural analgesia also improved progressively. Operative mortality decreased non-significantly to 4.7% and anastomotic leaks from 24% to 9.5% with a reduction in postoperative stay from 15 to 11 days during the period analysed (P=0.029).ConclusionsSeveral indicators have significantly improved in a relatively short period of time due to self-evaluations of the process.     

A comparison of epidural magnesium and/or morphine with bupivacaine for postoperative analgesia after cesarean section

BackgroundMagnesium can potentiate the antinociceptive effect of morphine. This prospective randomized double-blinded study was undertaken to establish the analgesic effect of adding magnesium to epidural morphine during cesarean section.MethodsTwo hundred patients undergoing cesarean section under combined spinal–epidural anesthesia were recruited. After administration of intrathecal bupivacaine 10 mg, patients were randomly assigned to receive one of four epidural study solutions: 0.1% bupivacaine 10 mL (Group B); 0.1% bupivacaine 10 mL and morphine 1.5 mg (Group B+Mor); 0.1% bupivacaine 10 mL and magnesium 500 mg (Group B+Mg); or 0.1% bupivacaine 10 mL morphine 1.5 mg and magnesium 500 mg (Group B+Mor+Mg). The primary outcome was the area under the curve for visual analog scale pain scores during 36 h postoperatively. Secondary outcomes included time to the use of rescue analgesics, patient satisfaction and side effects.ResultsPatients in Group B+Mor+Mg had lower for pain scores and area under the curve pain scores both at rest and on movement, increased time for first analgesic request, and increased satisfaction score at 24 h after surgery.ConclusionAddition of magnesium 500 mg and morphine 1.5 mg to epidural 0.1% bupivacaine 10 mL reduced postoperative pain compared with addition of morphine or magnesium alone or no additive.     

A randomised controlled trial of the effect of a head-elevation pillow on intrathecal local anaesthetic spread in caesarean section

BackgroundA head-elevation pillow places a patient in a ramped posture, which maximises the view of the larynx during laryngoscopy, particularly in obese parturients. In our institution an elevation pillow is used pre-emptively for neuraxial anaesthesia. We hypothesised that head-elevation may impair cephalad spread of local anaesthetic before caesarean section resulting in a lower block or longer time to achieve a T6 level. We aimed to investigate the effect of head-elevation on spread of intrathecal local anaesthetics during anaesthesia for caesarean section.MethodsOne-hundred parturients presenting for caesarean section under combined spinal-epidural anaesthesia were randomised to either the standard supine position with lateral displacement or in the supine position with lateral displacement on an head-elevation pillow. Each patient received intrathecal hyperbaric bupivacaine 11 mg, morphine 100 μg and fentanyl 15 μg. Patients were assessed for adequacy of sensory block (T6 or higher) at 10 min.ResultsSensory block to T6 was achieved within 10 min in 65.9% of parturients in the Elevation Pillow Group compared to 95.7% in the Control Group (P<0.05). Compared to the Control Group, patients in the Elevation Pillow Group had greater requirements for epidural supplementation (43.5% vs 2.1%, P<0.001) or conversion to general anaesthesia (9.3% vs 0%, P<0.04).ConclusionsUse of a ramped position with an head-elevation pillow following injection of the intrathecal component of a combined spinal-epidural anaesthetic for scheduled caesarean section was associated with a significantly lower block height at 10 min.     

Lovastatin inhibits adipogenesis and prevents osteonecrosis in steroid-treated rabbits

ObjectivesTo investigate in vivo effects of lovastatin on inhibition of adipogenesis, an important mechanism of steroid-induced osteonecrosis, and on prevention of occurrence of steroid-induced osteonecrosis in rabbits.MethodsFifty-four rabbits were intramuscularly injected once with 20 mg/kg of methylprednisolone acetate (MPSL). Then, they were divided into two groups: lovastatin was given in Group I and placebo was given in Group II. And another 16 rabbits were injected with physiologic saline (PS) as a control (Group III). Hematological examination was performed for serum lipid levels. Both the femora and the humeri were histopathologically examined for the presence of osteonecrosis before the injection and 1, 2, 4 and 12 weeks after the injection.ResultsThe serum lipid levels were significantly higher in Group II than in Groups I and III 1, 2 and 4 weeks after the injection. The incidence of osteonecrosis was significantly higher in Group II (69%) than in Group I (36%) and Group III (0%). Pathological examination showed less serious adipogenesis and bone death in Group I than in Group II. The size and area of the fat cells in the bone marrow were significantly smaller in Group I (47.5 ± 1.3 μm, 25%) and Group III (41.7 ± 1.6 μm, 12%) than in Group II (59.8 ± 6.3 μm, 51%) (P < 0.001).ConclusionLovastatin can prevent development of steroid-induced osteonecrosis in rabbits by inhibiting adipogenesis. Future evaluation on the effectiveness of lovastatin in the clinical practice is still necessary.     

An open-label randomized controlled clinical trial for comparison of continuous phenylephrine versus norepinephrine infusion in prevention of spinal hypotension during cesarean delivery

BackgroundDuring spinal anesthesia for cesarean delivery phenylephrine is the vasopressor of choice but can cause bradycardia. Norepinephrine has both β- and α-adrenergic activity suitable for maintaining blood pressure with less bradycardia. We hypothesized that norepinephrine would be superior to phenylephrine, requiring fewer rescue bolus interventions to maintain blood pressure.MethodsEighty-five parturients having spinal anesthesia for elective cesarean delivery were randomized to Group P (phenylephrine 0.1 μg/kg/min) or Group N (norepinephrine 0.05 μg/kg/min) fixed-rate infusions. Rescue bolus interventions of phenylephrine 100 μg for hypotension, or ephedrine 5 mg for bradycardia with hypotension, were given as required to maintain systolic blood pressure. Maternal hemodynamic variables were measured non-invasively.ResultsThere was no difference between groups in the proportion of patients who required rescue vasopressor boluses (Group P: 65.8% [n=25] vs. Group N: 48.8% [n=21], P=0.12). The proportion of patients who received ⩾1 bolus of phenylephrine was similar between groups (Group P: 52.6% [n=20] vs. Group N: 46.5% [n=20], P=0.58). However, more patients received ⩾1 bolus of ephedrine in the phenylephrine group (Group P: 23.7% [n=9] vs. Group N: 2.3% [n=1], P <0.01). The incidence of emesis was greater in the phenylephrine group (Group P: 26.3% vs. Group P: 16.3%, P <0.001). Hemodynamic parameters including heart rate, the incidence of bradycardia, blood pressure, cardiac output, cardiac index, stroke volume, and systemic vascular resistance and neonatal outcome were similar between groups (all P <0.05).ConclusionNorepinephrine fixed-rate infusion has efficacy for preventing hypotension and can be considered as an alternative to phenylephrine.     

The effect of adding magnesium sulphate to epidural bupivacaine and fentanyl in elective caesarean section using combined spinal–epidural anaesthesia: a prospective double blind randomised study

BackgroundCombined spinal–epidural anaesthesia is commonly used for elective caesarean section. Intrathecal injection produces rapid onset with minimal doses of local anaesthetic and epidural administration can be used to prolong the block. Our study examined the effects of adding magnesium sulphate to epidural bupivacaine and fentanyl in patients undergoing elective caesarean section using combined spinal–epidural anaesthesia.MethodsWomen ASA physical status I or II at term were recruited. All received 2 mL intrathecal 0.5% hyperbaric bupivacaine, 10 mL epidural 0.25% plain bupivacaine with fentanyl 100 μg, and were randomly allocated to receive either 10 mL of epidural 0.9% sodium chloride or 10 mL epidural 5% magnesium sulphate. The quality of surgical anaesthesia, incidence of hypotension, Apgar scores, intraoperative pain assessment, onset of postoperative pain, sedation scores and side effects were recorded in the postoperative period.ResultsNinety women were recruited. There was no difference in the time taken for the block to reach T4 sensory level, time to reach the highest level of sensory block, time interval between first neuraxial injection and onset of surgery between the groups. Women who received magnesium had greater motor block and muscle relaxation (P < 0.05). Apgar scores were 7 or more in almost all neonates in both groups. There was no significant difference in the incidence of hypotension, nausea and vomiting and duration of motor blockade between the groups. Women who received magnesium showed less shivering and later onset of post operative pain (P < 0.05).ConclusionThe addition of magnesium to epidural bupivacaine and fentanyl in women undergoing elective caesarean section with combined spinal–epidural anaesthesia improved intraoperative conditions and the quality of postoperative analgesia.     

Scheduled acetaminophen with as-needed opioids compared to as-needed acetaminophen plus opioids for post-cesarean pain management

BackgroundCombination opioid-acetaminophen drugs are commonly used for pain management after cesarean delivery. The aim of this study was to determine if scheduled acetaminophen decreases opioid use compared to as-needed combination acetaminophen-opioid administration.MethodsWe performed a retrospective chart review of women who underwent cesarean delivery before and after a clinical practice change. All patients received spinal anesthesia containing intrathecal morphine 200 μg and scheduled non-steroidal anti-inflammatory drugs for 48 h postoperatively. The first group (As-Needed Group, n=120) received combination oral opioid-acetaminophen analgesics as needed for breakthrough pain. The second group (Scheduled Group, n=120) received oral acetaminophen 650 mg every 6 h for 48 h postoperatively with oral oxycodone administered as needed for breakthrough pain. The primary outcome was opioid use, measured in intravenous morphine mg equivalents, in the first 48 h postoperatively.ResultsThe Scheduled Group used 9.1 ± 2.1 mg (95% CI 5.0–13.2) fewer intravenous morphine equivalents than the As-Needed Group (P <0.0001) over the study period. Fewer patients in the Scheduled Group exceeded acetaminophen 3 g daily compared to the As-Needed Group (P=0.008). Pain scores were similar between study groups.ConclusionsAfter cesarean delivery, scheduled acetaminophen results in decreased opioid use and more consistent acetaminophen intake compared to acetaminophen administered as needed via combination acetaminophen-opioid analgesics, without compromising analgesia.     

Lidocaine-tramadol versus lidocaine-dexmedetomidine for intravenous regional anesthesia

BackgroundIntravenous regional anesthesia (IVRA) has been used for more than a century. Both tramadol (synthetic opioid) and dexmedetomidine (α₂-agonist) can act locally.Aim of the workTo compare effects of adding tramadol versus dexmedetomidine to lidocaine during IVRA.Patients and methodsSixty patients were randomly assigned into: Group C (n = 20), Group T (n = 20), and Group D (n = 20). All patients received 3 mg/kg 0.5% lidocaine [+100 mg tramadol in Group T, or 1 μg/kg dexmedetomidine in Group D]. Times of onset and offset of sensory and motor blocks, and time to tourniquet pain were recorded. Postoperative VAS score, time to first dose, and total amounts of supplementary analgesia (Paracetamol) were recorded. Sedation was evaluated using Ramsay sedation scale (RSS).ResultsSignificantly shorter onset times and longer recovery times of sensory and motor block were recorded in Groups T and D compared to Group C (P < 0.05); while, with no significant differences between Groups T and D. Delayed onset of tourniquet pain occurred in Groups T and D compared to Group C (P < 0.05) with no significant differences between Groups T and D. Fourteen patients required fentanyl to control tourniquet pain in Group C compared to (5 and 4) in Groups T and D respectively. Significantly lower Postoperative VAS score, longer time to first dose and lower consumption of Paracetamol were recorded in Groups T and D than in Group C; with no significant differences between Groups T and D. Complications were skin rash in 30% of patients in Group T, bradycardia and sedation in 35% and 65% of patients in Group D respectively.ConclusionAddition of either tramadol or dexmedetomidine enhances lidocaine during IVRA with higher incidence of skin rash with tramadol and postoperative bradycardia and sedation with dexmedetomidine.     

Randomized double-blind comparison of ephedrine and phenylephrine for management of post-spinal hypotension in potential fetal compromise

BackgroundMost studies comparing phenylephrine and ephedrine have been conducted during elective caesarean sections in healthy mothers with no fetal compromise. The effect of vasopressors on fetal outcome may differ between healthy and compromised fetuses. There has been little research into the effect of phenylephrine and ephedrine, when used for management of post-spinal hypotension in the presence of potential fetal compromise.MethodsHealthy women with a singleton pregnancy undergoing emergency caesarean section for fetal compromise under spinal anaesthesia were studied. One-hundred-and-six consecutive subjects, who developed hypotension after spinal anaesthesia, were randomly allocated to two groups of 53 each, to receive either phenylephrine (Group P) or ephedrine (Group E). For every systolic blood pressure reading <100 mmHg patients received phenylephrine 100 μg or ephedrine 8 mg depending on group allocation. Umbilical blood gas parameters and Apgar scores were recorded.ResultsThere was no statistically significant difference in umbilical arterial pH (P=0.79), umbilical venous pH (P=0.98), other blood gas parameters, incidence of fetal acidosis (P=1.00) and Apgar scores. The number of hypotensive episodes, vasopressor doses for treatment of the first hypotensive episode and the total number of doses used during the study period were comparable. The median [IQR] total number of doses of phenylephrine and ephedrine used before delivery were 2 [1–2] and 2 [1–2], respectively (P=0.67). More patients receiving ephedrine (24.5%) developed tachycardia than those receiving phenylephrine (3.8%) (P=0.004). Bradycardia was more common with phenylephrine, with 39.6% of patients in Group P as compared to only 1.9% of patients in Group E developing a heart rate <60 beats/min after vasopressor administration (P=0.001).ConclusionsBoth phenylephrine 100 μg and ephedrine 8 mg boluses are equally efficacious when treating post-spinal hypotension in the presence of potential fetal compromise. However, phenylephrine may be a better choice in the presence of maternal tachycardia.     

Effectiveness of CT-guided epidural infiltration of steroids and local anesthetics for acute and chronic herpes zoster neuralgia

PurposeThe purpose of this study was to evaluate the effectiveness and complication rate of computed tomography (CT)-guided epidural injection of steroids and local anesthetics for pain relief in patients with neuralgia due to acute or chronic herpes zoster (HZ).Materials and methodsA prospective study was conducted from April 2017 to February 2019 including patients with HZ neuralgia (HZN) at any stage (acute or chronic, the latter being defined as pain lasting more than 3 months and also called post herpetic neuralgia [PHN]). The sensory ganglion of the affected dermatome and/or the affected sensory nerve was targeted under CT-guidance and local injection of a mixture of two vials of methylprednisolone 40 mg/mL and 2 mL of Lidocaine 1% was performed. Using a visual analogue scale (VAS, 0 to 10), pain was assessed prior to the procedure, and at day 7, 1 month, 3 months and 6 months. Adverse effects were graded according to the Society of Interventional Radiology classification.ResultsTwenty patients were included. There were 9 men and 11 women with a mean age of 67 ± 13.9 (SD) years (range: 27–83 years). Of these, 14 patients had acute HZN and 6 had PHN. Mean VAS at baseline was 8.1 ± 1.2 (SD) (range: 6–10) with significant decrease (P < 0.0001) at day 7 (3.4 ± 3.2 [SD]; range: 0–10), day 30 (3.4 ± 3.2 [SD]; range: 0–9), day 90 (2.9 ± 3.2 [SD]; range: 0–9), and day 180 (2.5 ± 3.1 [SD]; range: 0–9). Infiltrations were significantly more effective on acute HZN than on PHN (P < 0.001) and required significantly fewer infiltrations for pain relef (P = 0.002). Only one grade A adverse event was reported.ConclusionEpidural injection of a mixture of steroids and local anesthetics under CT-guidance is effective on HZN with a persisting effect over 6 months.     

The effects of prophylactic bolus phenylephrine on hypotension during low-dose spinal anesthesia for cesarean section

BackgroundContinuously infused phenylephrine is frequently used to reduce the incidence of hypotension in women undergoing cesarean section under spinal anesthesia, but less is known about the prophylactic bolus method. We evaluated three prophylactic bolus doses of phenylephrine during low-dose spinal anesthesia for cesarean section.MethodsOne-hundred-and-eighty-four patients were randomized to receive 0.9% saline 2 mL (Control Group) or phenylephrine 1.0 μg/kg (PHE1 Group), 1.5 μg/kg (PHE1.5 Group), or 2.0 μg/kg (PHE2 Group) immediately after induction of combined spinal-epidural anesthesia. Maternal blood pressure and heart rate were recorded at 1-min intervals until delivery. Hypotension, defined as systolic blood pressure <80% of baseline, was treated with rescue doses of phenylephrine 100 μg at 1-min intervals until hypotension resolved. The incidence of nausea, vomiting, bradycardia, and hypertension, as well as Apgar scores and umbilical blood gases, were recorded.ResultsThe incidence of hypotension was 71.7% (33/46) in the Control Group, 68.9% (31/45) in the PHE1 Group, 37.0% (17/46) in the PHE1.5 Group and 45.7% (21/46) in the PHE2 Group (P=0.001). The total rescue dose of phenylephrine was greater in the Control Group than those in the PHE1.5 Group (P <0.05) and PHE2 Group (P <0.05). The incidence of hypertension increased as the dose of prophylactic phenylephrine increased (P <0.001) and was highest in the PHE2 group (37%). Other variables did not differ among the four groups.ConclusionsUnder the conditions of this study, prophylactic bolus injection of phenylephrine 1.5 μg/kg was a suitable alternative method for reducing the incidence of hypotension during low-dose spinal anesthesia for cesarean section.     

ACTH as first line treatment for acute gout in 181 hospitalized patients

ObjectiveWe aimed at assessing the efficacy and safety of adrenocorticotropic hormone (ACTH) for the treatment of acute gout in hospitalized patients.MethodsWe retrospectively reviewed our inpatient consultation records and identified 181 cases of gout where ACTH was used as first line treatment. The hospital medical records of these patients were fully reviewed. A total of 181 patients were treated with 1 mg of synthetic ACTH intramuscularly.ResultsA response was seen in 77.90% of patients and was evident the day following ACTH injection. The majority of non-responders (87.50%) were treated once more with ACTH the day following the first injection; 82.85% of these patients responded. A relatively small percentage of responders suffered a second gouty attack (11.34%) at a median of four days from the initial attack. They were retreated with a single ACTH course and all responded. Blood pressure and potassium levels remained stable 24 and 48 hours following ACTH administration. Diabetic patients showed an increase in fasting glucose levels 24 hours following the injection compared to baseline but this increase was not evident at 48 hours.ConclusionsOur data indicate that ACTH is effective and safe for the treatment of gout in hospitalized patients. ACTH is an attractive therapeutic option for hospitalized patients since the use of non-steroidal anti-inflammatory drugs, steroids or colchicine in this patient population may be problematic.     

Postural change from lateral to supine is an important mechanism enhancing cephalic spread after injection of intrathecal 0.5% plain bupivacaine for cesarean section

BackgroundSpinal anesthesia is widely used for cesarean section, but the factors that affect the spread of the block in pregnant patients are still not fully explained. This study was designed to investigate the effect of postural changes on sensory block level.MethodsThirty patients scheduled for elective cesarean section under combined spinal–epidural anesthesia were randomly allocated into three groups. After intrathecal injection of 0.5% plain bupivacaine 7.5 mg, patients in group S were immediately placed in the supine position with left tilt, patients in group L5 were kept lateral for 5 min and then turned to the supine position with left tilt, and patients in group L10 were kept lateral for 10 min and then turned to the supine position with left tilt.ResultsAt 5 min, median cephalad level of sensory block was lower in groups L5 and L10 compared with group S (corrected P<0.001); at 10 min, median cephalad sensory block level was lower in group L10 compared with group S (corrected P<0.001) and group L5 (corrected P<0.001), and lower in group L5 compared with group S (corrected P=0.033); at 15 min, median cephalad level of sensory block was lower in group L10 compared with group S (corrected P=0.003) and group L5 (corrected P=0.015).ConclusionsIn our population, using 0.5% plain bupivacaine 7.5 mg, postural change from the lateral position to the supine position is an important mechanism enhancing cephalic spread of spinal anesthesia during late pregnancy.     

Pencil-point needle bevel direction influences ED50 of isobaric ropivacaine with fentanyl in spinal anesthesia for cesarean delivery: a prospective,double-blind sequential allocation study

BackgroundThere is little evidence on the influence of bevel direction of a pencil-point needle on the median effective dose (ED50) of isobaric ropivacaine and fentanyl in spinal anesthesia for cesarean delivery.MethodsIn this prospective, double-blind, sequential allocation study, 82 parturients scheduled for elective cesarean delivery under combined spinal-epidural anesthesia were included. We sought to determine the median effective dose of intrathecal 0.75% isobaric ropivacaine plus fentanyl 15 μg with two different bevel directions of a 26-gauge Whitacre needle using up-down sequential allocation. Parturients were randomly allocated to either Group Ce (needle aperture oriented in a cephalad direction) or Group Ca (aperture directed caudally). The initial dose was 0.75% ropivacaine 11.25 mg plus fentanyl 15 μg in both groups. Each dose was classified as effective if, after 15 min and during the next 60 min, there was inability to appreciate pin-prick as sharp at T4, a visual analogue pain score <2 and no requirement for an epidural rescue bolus.ResultsEighty patients were included in the analysis. The ED50 in group Ca was significantly higher (13.09 mg, 95% CI 12.19–14.00) than in group Ce (10.10 mg, 95% CI 9.54–10.65, P <0.001).ConclusionThe orientation of the distal aperture of a 26-gauge Whitacre needle during induction of spinal anesthesia for cesarean delivery influences the ED50 of 0.75% ropivacaine.     

A randomized controlled trial using patient-controlled epidural analgesia with 0.25% versus 0.0625% bupivacaine in nulliparous labor: effect on analgesia requirement and maternal satisfaction

BackgroundThe effect of epidural local anesthetic concentration on analgesic action is still the subject of debate. This study compared the effect of a four-fold change in concentration of bupivacaine for epidural analgesia in labor.MethodsNulliparous women in early active labor were recruited. All women received analgesic drugs via a lumbar epidural catheter, and all received fentanyl 1 μg/kg with the epidural induction dose and no further opioids throughout the study. Patients were randomized to receive either a 5-mL bolus followed by a 5-mL/h infusion of concentrated (0.25%) bupivacaine or a 20-mL bolus followed by a 20-mL/h infusion of dilute (0.0625%) bupivacaine. Patient-controlled epidural analgesia of the study solution was then used to assess additional analgesia requirements. Analgesic requirement, maternal satisfaction and obstetric outcome were compared.ResultsFor subjects receiving 0.25% bupivacaine, the median total dose of drug administered was greater (117 vs. 90 mg, P = 0.0008), and the mean maternal satisfaction score was less (82 vs. 93, P = 0.04) than with the 0.0625% solution.ConclusionsLarger volumes of more dilute solutions may result in dose sparing and provide more effective labor analgesia. This study supports the continued trend towards dilute local anesthetic mixtures for labor epidural analgesia.