Could ephedrine replace meperidine for prevention of shivering in women undergoing Cesarean Section under spinal anesthesia? A randomized study

PurposeTo compare possible unlabeled effect of ephedrine, as shivering prophylaxis, with meperidine during spinal anesthesia for Cesarean Section.MethodsAfter institutional ethical committee approval, 96 parturients scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated according to shivering prophylaxis to receive either 15 mg meperidine (group M, n = 48) or 6 mg ephedrine (group E, n = 48) intravenously before spinal block. Incidence and intensity of shivering as well as side effects of either drug were assessed.ResultsThe incidence shivering in meperidine and ephedrine groups in women undergoing Cesarean Section under spinal anesthesia was comparable (27%, 29% respectively, P = 0.06). Also, intensity of shivering was not different between two groups. Moreover, phenylephrine requirement and incidence of nausea and vomiting were significantly less in ephedrine group (121 ± 2.2% and 4.1% respectively) relative to meperidine group (168 ± 3.2% and 16.6% respectively).ConclusionThe prophylactic use of a low dose ephedrine is effective as meperidine for shivering prophylaxis in women undergoing Cesarean Section under spinal anesthesia as meperidine. Moreover, it is associated with less hypotension, nausea and vomiting.     

Continuous epidural pumping of saline contributes to prevent and treat postdural puncture headache

Study ObjectivePostdural puncture headache (PDPH) is the most common symptom of accidental dural puncture, a frequent complication of intraspinal anesthesia. We developed a postoperative intervention technique to prevent and treat PDPH in accidental dural puncture patients, including epidural pumping of saline. This retrospective study aimed to retrospectively evaluate this new technique for PDPH prevention and treatment.DesignRetrospective study.SettingBeijing Obstetrics and Gynecology Hospital affiliated to the Capital Medical University, between January 2006 and December 2012.PatientsEighty-seven cases undergoing intraspinal anesthesia were assessed.InterventionsOf these patients, 68 cases had successful repuncture and were assigned to group A (epidural filling group, n = 68), receiving continuous epidural pumping of 0.9% NS (150 mL) at a rate of 6 mL/h; the remaining cases were assigned to group B (conservative therapy group, n = 19).MeasurementsAge, height, and body weight were collected, and postoperative headache was assessed using a visual analog scale.Main ResultsOf 68 patients in group A, 49 (72.1%) developed PDPH, whereas all in group B developed PDPH (P = .009). In addition, all patients showed PDPH within 3 days after surgery regardless of treatment group. However, a statistically significant difference was obtained for PDPH duration between groups A and B (P < .001). Multivariate logistic regression analysis showed that frequency of epidural puncture and continuous epidural pumping of saline were significant risk factors for PDPH.ConclusionsOur data indicated that application of 6 mL/h saline effectively contributes to PDPH management, and its clinical application should be broadened.     

Prévention de l’hypotension induite par la rachianesthésie au cours de la césarienne programmée : coremplissage par HEA 130/0,4 vs sérum salé isotonique

ObjectiveThe aim of this study was to compare the efficacy of HES 130/0.4 coloading compared to normal saline solution for prevention of hypotension during spinal anesthesia for elective caesarean section.Study designProspective, randomized.Patients and methodsOne hundred and twenty ASA I and II patients scheduled for elective caesarean section were recruited. Patients were randomized to receive either 500 mL of HES 130/0.4 (Voluven^®) coloading (Group V) or 500 mL of normal saline solution coloading (Group C). Spinal anesthesia technique and ephedrine administration were standardized in both groups. The primary endpoint was the incidence of maternal hypotension during spinal anesthesia for elective caesarean section.ResultsHypotension occurred in 43 patients in group C and 24 patients in group V (p = 0.001). Ephedrine consumption was significantly lower in group V (P = 0.005). Nausea, vomiting and headache incidence was higher in group C (p = 0.006). Apgar scores and umbilical blood gazes were comparable between groups.ConclusionHES 130/0.4 coload was more effective than normal saline solution to prevent hypotension following spinal anesthesia for elective cesarean section. HES 130/0.4 coload reduced the incidence, the duration of longest hypotension, the need for ephedrine and the adverse maternal effects.     

Caffeine,Is it effective for prevention of postdural puncture headache in young adult patients?

Background and objectivesPostdural puncture headache is a relatively common complication in spinal anesthesia, so several kinds of regimens have been suggested for treatment of this problem. The aim of this study was to evaluate the efficacy and safety of prophylactic administration of intravenous caffeine sodium benzoate for prevention of postdural puncture headache (PDPH) in young adult patients received spinal anesthesia.MethodsOne hundred ASA I and II patients undergoing elective knee surgeries either arthroscopy or anterior cruciate ligament reconstruction (ACL reconstruction) were included in this study. Patients were randomized by double-blind, placebo-controlled design to receive intravenously (IV) either 10 mL normal saline as control group (group S) or 10 ml with 500 mg caffeine sodium benzoate (CSB) as caffeine group (group C) during the first 60 min after spinal anesthesia administration. The patient’s electrocardiogram, noninvasive blood pressure, and pulse oximetry were monitored and recorded. The patients’ headaches were evaluated by using the visual analog scale (VAS), and the severity of the headache was classified as follows: no headache = 0, mild headache ⩽3, moderate headache from 4 to 6 and severe headache ⩾7. Analgesic requirements were recorded.ResultsVisual analog scale scores were significantly lower in group C than in group S. The incidence of moderate and severe headache was significantly higher in group S (11 patients) when compared with group C (2 patients). Analgesic demand was significantly lower in group C than in group S.ConclusionIt seems that the incidence of postdural puncture headache decreases in those patients who received caffeine sodium benzoate. The article can potentially help clinicians to use caffeine as an effective drug for prevention of PDPH.     

The efficacy of preoperative pregabalin on reduction of the incidence and severity of postdural puncture headache after spinal anesthesia

ObjectiveThe aim of this study was to evaluate the efficacy of prophylactic pregabalin on postdural puncture headache incidence and severity after spinal anesthesia.Method86 ASA I-II male and female patients age 20–50 years old, undergoing elective general surgeries below the umbilicus under spinal anesthesia with 3 ml heavy bupivacaine 0.5% (15 mg), patients were randomly allocated into one of two groups (Group C, n = 43) (control group) received a placebo capsule 2 h preoperatively (Group P, n = 43) received 150 mg pregabalin capsule 2 h preoperatively, number of attempts for spinal block, sensory level, motor block grade, postoperative time to first analgesic requirement, the incidence, onset and intensity of PDPH and adverse events were recorded for 72 h.ResultsThe peak sensory level in C group and P group showed no statistical significant difference, the time to peak sensory block was significantly earlier in P group than group C, the time to reach the modified Bromage motor block grade 3 was significantly earlier in P group than C group, time to two segment regression of sensory level to S1 and motor block regression to modified Bromage grade 0 were statistically insignificant between the studied groups. Group P had a significantly longer time to first analgesic requirements than group C, and there was no significant difference in VAS (visual analogue scale) of pain between the studied groups. There was significant increase in sedation score in P group compared to C group at 2 h and 6 h postoperatively, and there was statistically significant reduction in the incidence rate and severity of PDPH in P group compared to group C. There were no recorded cases of dizziness, visual disturbances, or PONV.Conclusionspreoperative oral pregabalin 150 mg reduced the incidence and severity of PDPH, beside the earlier onset of peak sensory and motor block with increase duration of analgesia in patients undergoing elective surgeries under spinal anesthesia.     

Postdural puncture headache after spinal anesthesia in cesarean section: Experience in six months in 2736 patients in Kasr El aini teaching hospital – Cairo University

BackgroundThis is a prospective, single-blinded observational study examined the frequency and severity of postdural puncture headache in the Egyptian female patients following spinal anesthesia for cesarean section.MethodAll the females scheduled for cesarean section under spinal anesthesia in Cairo university were included and divided into two groups, one with Quinke needle G22 and one with Quinke needle G20, both groups were followed up for 7 days regarding incidence and severity of PDPH.ResultThe overall incidence of postdural puncture headache was 32.58% in group with Quinke needle G22, while it was 32.86% with the group used Quinke needle G20, PDPH almost relived by the fifth day in both groups, patients rated their headache as mild to moderate on a 10-cm visual analog scale.ConclusionsThis study is a documentation of the Cairo University teaching hospital experience with PDPH in female patient undergoes spinal anesthesia, and it focus on the incidence and severity related to the needle size and Egyptian population. We recommend the usage of the pencil point needle or a smaller needle in Cairo university hospital regardless the economic, teaching and manufacturing reasons.     

Hetastarch co-loading is as effective as pre-loading for the prevention of hypotension following spinal anesthesia for cesarean delivery

BackgroundPre-loading with hetastarch decreases the incidence and severity of hypotension after spinal anesthesia for cesarean delivery. However, pharmacokinetic studies with crystalloid predict that fluid loading should be more efficacious if rapidly administered immediately after induction of spinal anesthesia. The aim of this study was to compare pre- and co-loading of hetastarch for the prevention of hypotension following spinal anesthesia for cesarean delivery.MethodsForty-six healthy term parturients scheduled for cesarean delivery were randomized to receive 500 mL of 6% hetastarch intravenously, either slowly before spinal anesthesia (pre-loading) or as quickly as possible immediately after spinal anesthesia (co-loading). Systolic blood pressure was maintained at or above 90% of baseline with intravenous vasopressor boluses (ephedrine 5 mg/mL + phenylephrine 25 μg/mL). The primary outcome was the volume of vasopressor mix required. Secondary outcomes included blood pressure and heart rate changes, time to first vasopressor use, nausea or vomiting, and neonatal outcomes (umbilical artery and vein pH, Apgar scores).ResultsThe pre-loading group used 3.5 ± 2 mL (mean ± SD) of vasopressor mixture compared with 3.2 ± 3 mL in the co-loading group (P = 0.6). There were no differences in any important maternal hemodynamic or neonatal outcome values between the two study groups.ConclusionHetastarch co-loading is as effective as pre-loading for the prevention of hypotension after spinal anesthesia for cesarean delivery. Surgery need not be delayed to allow a predetermined pre-load to be administered before induction of spinal anesthesia.     

O efeito de epinefrina,norepinefrina e fenilefrina no tratamento da hipotensão pós‐raquianestesia: estudo clínico comparativo

Background and objectivesLimited data are present on safety and efficiency of epinephrine for the prophylaxis and treatment of spinal‐hypotension. This study was conducted to compare the effect of epinephrine with norepinephrine and phenylephrine on the treatment of spinal‐hypotension and ephedrine requirement during cesarean delivery.MethodsOne hundred and sixty parturients with uncomplicated pregnancies undergoing elective cesarean delivery under spinal anesthesia were recruited. They were allocated randomly to receive norepinephrine 5 μg.mL^‐1 (n = 40), epinephrine 5 μg.mL^‐1 (n = 40), phenylephrine 100 μg.mL^‐1 (n = 40) or 0.9% saline infusions (n = 40) immediately after induction of spinal anesthesia. Whenever systolic blood pressure drops to less than 80% of baseline, 5 mg of iv ephedrine was administered as rescue vasopressor. The incidence of hypotension, total number of hypotension episodes, the number of patients requiring ephedrine, the mean amount of ephedrine consumption and side effects were recorded.ResultsThere was no statistically significant difference in incidence of maternal hypotension between groups. The number of patients requiring ephedrine was significantly greater in group saline than in group phenylephrine (p < 0.001). However, it was similar between phenylephrine, norepinephrine, and epinephrine groups. The mean ephedrine consumption was significantly higher in group saline than in norepinephrine, epinephrine, phenylephrine groups (p = 0.001).ConclusionThere is no statistically significant difference in incidence of hypotension and ephedrine consumption during spinal anesthesia for cesarean delivery with the use of epinephrine when compared to norepinephrine or phenylephrine. Epinephrine can be considered as an alternative agent for management of spinal hypotension.     

Single shot spinal anesthesia with very low hyperbaric bupivacaine dose (3.75 mg) for hip fracture repair surgery in the elderly. A randomized,double blinded study

PurposeSingle shot spinal anesthesia is used worldwide for hip fracture repair surgery in the elderly. Arterial hypotension is a frequent adverse effect. We hypothesized that lowering local anesthetics dose could decrease the incidence of arterial hypotension, while maintaining quality of surgical anesthesia.MethodsIn a randomized double blinded study, 66 patients over the age of 65 years, with hip fracture needing surgical repair, were assigned to B0.5 group 7.5 mg hyperbaric bupivacaine 5 mg/ml (control group), and B0.25 group 3.75 mg hyperbaric bupivacaine 2.5 mg/ml (study group). Sensory and motor block level, and hemodynamic parameters including blood presure, heart rate and vasopressor dose administration were registered, along with rescue anesthesia needs, the feasibility of surgery, its duration, and regression time of sensory anesthesia to T12.ResultsAfter exclusions, 61 patients were included in the final analysis. Arterial hypotension incidence was lower in the B0.25 group (at the 5, 10, and 15 min determinations), and a lower amount of vasopressor drugs was needed (mean accumulated ephedrine dose 1.6 mg vs. 8.7 mg in the B0.5 group, p < 0.002). Sensory block regression time to T12 was shorter in the B0.25 group, mean 78.6 ± 23.6 (95% CI 51.7–110.2) min vs. 125.5 ± 37.9 (95% CI 101.7–169.4) min in the B0.5 group, p = 0.033. All but one patient in the B0.25 group were operated on under the anesthetic procedure first intended. No rescue anesthesia was needed.ConclusionLowering bupivacaine dose for single shot spinal anesthesia for hip fracture repair surgery in elderly patients was effective in decreasing the occurrence of arterial hypotension and vasopressor use, while intraoperative quality remained.     

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.     

Comparison between colloid preload and crystalloid co-load in cesarean section under spinal anesthesia: a randomized controlled trial

BackgroundHypotension is a common problem during spinal anesthesia for cesarean delivery. Intravenous fluid loading is used to correct preoperative dehydration and reduce the incidence and severity of hypotension. Different fluid regimens have been studied but colloid preload and crystalloid co-load have not been compared.MethodsIn this randomized double-blind study, 210 patients scheduled for elective cesarean section under spinal anesthesia were randomly allocated to receive either 6% hydroxyethyl starch 130/0.4 500 mL before spinal anesthesia (colloid preload) or Ringer’s acetate solution 1000 mL administered rapidly starting with intrathecal injection (crystalloid co-load). Maternal hypotension (systolic blood pressure <80% of baseline or <90 mmHg) and severe hypotension (systolic blood pressure <80 mmHg) were treated with 5 and 10 mg ephedrine boluses, respectively. The primary outcome was the incidence of hypotension. Secondary outcomes included the incidence of severe hypotension, total ephedrine dose, nausea and vomiting and neonatal outcome assessed by Apgar scores and umbilical artery blood gas analysis.ResultsData analysis was performed on 205 patients; 103 in the colloid preload group and 102 in the crystalloid co-load group. There were no significant differences in the incidence of hypotension (52.4% vs. 42.2%; P=0.18) or severe hypotension (15.5% vs. 9.8%; P=0.31) between colloid preload and crystalloid co-load groups, respectively. The median [range] ephedrine dose was 5 [0–45] mg in the colloid preload group and 0 [0–35] mg in the crystalloid co-load group (P=0.065). There were no significant differences in maternal nausea or vomiting or neonatal outcomes between groups.ConclusionThe use of 1000 mL crystalloid co-load has similar effect to 500 mL colloid preload in reducing the incidence of hypotension after spinal anesthesia for elective cesarean delivery. Neither technique can totally prevent hypotension and should be combined with vasopressor use.     

Anestesia subaracnoidea y anestesia general en el tratamiento quirúrgico de la hernia inguinal en pacientes ambulatorios. Análisis comparativo de coste-efectividad

ObjectiveTo compare the costs related to the clinical effectiveness of general anesthesia versus spinal anesthesia in inguinal hernioplasty ambulatory surgery.Material and methodsAn observational, retrospective cohort study measurement and analysis of cost-effectiveness, in the ambulatory surgery unit of a general hospital. All patients over 18 years of age diagnosed with primary inguinal hernia and scheduled for unilateral hernioplasty between January 2010 and December 2011 were included. Duration of anesthetic induction, length of stay in both the operating room, and in the post-anesthesia care unit, the anesthetic effectiveness (the incidence of adverse effects and the patient's comfort level), and variable economic costs associated with the use of drugs, as well as the use of human resources, were compared.ResultsThe final analysis included 218 patients, 87.2% male, with a mean age of 53 years (range: 18-85 years). Of these, 139 (63.76%) received subarachnoid anesthesia and 79,(36.2%) general anesthesia. The length of time a patient remained in the post-anesthesia care unit was 337.6 ± 160.2 min in the subarachnoid anesthesia group, and 210.0 ± 97.5 min for the general anesthesia group (P < .001). Costs of drugs for general anesthesia were higher than that for subarachnoid anesthesia (86.2 ± 8.3 vs. 18.7 ± 7.2). The total cost difference between the 2 techniques was €115.8 more for subarachnoid anesthesia (P < .001).ConclusionsBoth techniques showed similar effectiveness. The overall costs for subarachnoid anesthesia were greater than for the general. The cost-effectiveness of general anesthesia is better for outpatient inguinal hernia repair surgery.     

Sequential higher epidural catheter re-insertion after accidental dural puncture ameliorates the frequency and severity of post-dural puncture headache

ObjectivesThis cohort study aimed to evaluate the outcome of a hypothesis to use higher level for epidural catheter insertion and activation when an epidural tap was encountered at a lower level during epidural analgesia for labor pain.MethodsEpidural analgesia for labor pain was conducted using a mixture of 0.125% bupivacaine and fentanyl 5 μg/ml (10–15 ml) in 5-ml increments and maintained using continuous epidural infusion of 0.125% bupivacaine and fentanyl 2 μg/ml at rate of (5–15 ml/h), subsequently adjusted according to the patients needs. All cases had accidental dural puncture (ADP) were managed immediately with re-insertion of the needle at a higher level and completion of the procedure and maintained using continuous epidural infusion of 0.0625% bupivacaine and fentanyl 2 μg/ml at rate of (6–12 ml/h) for 24 h after delivery. Postpartum follow-up was conducted for 30 days to comment on the occurrence and severity of post-dural puncture headache (PDPH). All patients developed PDPH were followed daily until resolution of their headache.ResultsAbout 4800 parturient were enrolled in the study, ADP occurred in 24 patients with a frequency of 0.5%. All cases were immediately managed by re-insertion of the needle at a higher level and the procedure was successfully completed without new dural puncture, with 100% re-insertion success rate, and patients were maintained on continuous epidural infusion for 24 h. Throughout 30-day follow-up; only six of 24 patients developed PDPH with a success rate of re-insertion procedure as a prophylactic modality for PDPH after ADP of 75%. PDPH was relieved with bed rest, liberal fluids and paracetamol for 4 days in four patients, while the 5th patient continued to complain but the patient refused to undergo epidural blood patch (EBP) and headache started to subside and patient stopped to complain by the 10th day, and the last patient agreed to undergo EBP; and headache was relived immediately after 2 h.ConclusionIt could be concluded that re-insertion of epidural catheter at higher level of accidental dural puncture with epidural continuous infusion for 24 h could be considered as an efficient prophylactic modality to safe guard against PDPH with success rate of 75% and minimizes its severity if occurred.     

A new modality for improving the efficacy of intrathecal injection for cesarean section

BackgroundIntrauterine resuscitation (IUR) is to improve O2 delivery to the placenta and umbilical blood flow, for reversal of foetal hypoxia and acidosis. We evaluated whether maintaining a lateral position after an intrathecal injection of a relatively low dose of hyperbaric bupivacaine and high dose of fentanyl improving the efficacy of spinal anaesthesia, IUR and preventing hypotension during cesarean delivery.MethodsOne hundred and seventy two healthy women undergoing elective cesarean delivery were enrolled in a double blind prospective randomized study. Spinal anesthesia was conducted in the right lateral position which maintained for 6 min for all the patients participated in the study, and then the subjects were turned supine. Patients were randomly allocated to two groups: low-dose spinal bupivacaine (LD) group (n = 86) patients received 6 mg of hyperbaric bupivacaine 0.5% and 15 μg of fentanyl, high-dose spinal bupivacaine (HD) group (n = 86) patients received 10 mg of hyperbaric bupivacaine and 15 μg of fentanyl. The incidence of hypotension and nausea, ephedrine requirement, maximal block height, and Apgar score at 1 and 5 min.ResultsThe authors found significant decrease in MAP in the group that was given the high dose of bupivacaine the incidence of hypotension was 80% but the LD spinal bupivacaine group was hemodynamically stable. The lowest blood pressure, boluses of inj. ephedrine used, or nausea were more significant in the HD group than in LD group. Onset of hypotension was more rapid (8 ± 3 vs. 16 ± 6 min, P < 0.001), and the sensory block level was more cephalad in HD group than in LD group (T2 [C8–T5] vs. T4 [T1–T6], P = 0.001). Apgar scores did not differ between the groups.ConclusionMaintaining the lateral position for 6 min after an intrathecal injection of a relatively low dose of hyperbaric bupivacaine and high dose of fentanyl resulted in improving the efficacy of spinal anaesthesia, IUR by more gradual and higher cephalad sensory block, without an increase in the incidence of maternal hypotension.     

A randomized study of maternal serum cytokine levels following cesarean section under general or neuraxial anesthesia

BackgroundCytokines are significant mediators of the immune response to surgery and also play a role in parturition. The aim of the study was to investigate the impact of the anesthetic technique for cesarean section on plasma levels of cytokines IL-6 and TNF-α.MethodsThirty-five parturients scheduled for elective cesarean section were randomly assigned to general (n = 18) or neuraxial (n = 17) anesthesia. The general anesthesia group received thiopental 4 mg/kg, succinylcholine 1–1.5 mg/kg and 1% end-tidal concentration of sevoflurane in nitrous oxide and 50% oxygen. The neuraxial anesthesia group received intrathecal 0.5% levobupivacaine 1.8–2.2 mL and epidural fentanyl 1 μg/kg. Blood samples were taken for IL-6 and TNF-α immediately after positioning the parturient on the operating table, after uterine incision and before the umbilical cord clamping and 24 h after surgery (T₁, T₂ and T₃ respectively).ResultsThe two groups did not differ in IL-6 (P = 0.15) or TNF-α (P = 0.73) serum concentrations at any time point. In the general and neuraxial anesthesia groups, IL-6 serum concentrations were significantly higher in the third blood sample, T₃ (12.2 ± 5.0 and 15.2 ± 4.3 pg/mL), than in T₁ (0.41 ± 0.38 and 0.29 ± 0.10 pg/mL) and T₂ (0.37 ± 0.47 and 0.24 ± 0.05) respectively (P < 0.001). Within each group, serum TNF-α concentrations did not differ significantly over time (P = 0.44).ConclusionsUnder the present study design anesthetic technique did not affect IL-6 or TNF-α concentrations in parturients undergoing elective cesarean section. Serum IL-6 levels increased 24 h postoperatively independently of anesthetic technique.     

Neonatal effects after vasopressor during spinal anesthesia for cesarean section: a multicenter,randomized controlled trial

BackgroundPlacental transfer of ephedrine causes fetal effects when compared with phenylephrine. This study compared their drug effects on neonatal parameters after cesarean delivery under spinal anesthesia.MethodsThree-hundred-and-fifty-four women undergoing elective cesarean delivery who needed intravenous vasopressor following spinal anesthesia were randomized into two groups. Group E received boluses of ephedrine 6 mg, and Group P phenylephrine 100 µg, titrated to maintain systolic blood pressure near baseline values. Neonatal heart rates at 10 and 30–45 min of age, oxygen saturation and capillary blood glucose at 30 min, and capillary blood lactate and urine metamphetamine were recorded.ResultsNeonatal heart rate at 10 min was significantly higher (mean difference 4.0, 95%CI 0.6 to 7.3, P=0.02) in Group E versus Group P, but this was not clinically relevant. There was a linear correlation between neonatal heart rate at 10 min and ephedrine dose in Group E (r²=0.29, 95%CI 0.22, 0.74, p <0.01). The decremental changes in neonatal heart rate at 10 and 30 min were significantly greater in Group E. Urine metamphetamine tests were positive in 19% of 44 neonatal urine samples. Neonatal heart rates at 30 min, oxygen saturation, capillary blood glucose and the incidence of tachycardia, respiratory problems or abnormal glucose, were not significantly different.ConclusionsEphedrine, compared to phenylephrine as a vasopressor during cesarean delivery, was associated with higher neonatal heart rate in the early post-birth period, but without a significant difference in clinical outcomes in uncomplicated pregnancies.     

Preoperative anterior thigh temperature does not correlate with perioperative temporal hypothermia during cesarean delivery with spinal anesthesia: Secondary analysis of a randomized control trial

BackgroundCore-to-peripheral redistribution of heat, secondary to sympathetic-mediated vasodilation, is the major mechanism leading to early perioperative hypothermia after neuraxial anesthesia. The study aim was to determine if preoperative anterior thigh (peripheral lower extremity) temperature predicted perioperative temporal (core) temperature decrease during cesarean delivery with spinal anesthesia.MethodsSecondary analysis of data derived from a prospective, randomized study of 46 healthy women undergoing scheduled cesarean delivery with spinal anesthesia was performed. Anterior thigh temperature was measured preoperatively prior to spinal anesthesia. The primary outcome was maximum perioperative temporal temperature decrease. Secondary outcomes included incidence of temporal hypothermia (temperature <36°C), shivering, and thermal comfort scores. This study ran concurrently with a previously published trial comparing no active intraoperative warming with active warming.ResultsThere was no correlation between preoperative anterior thigh temperature and maximum perioperative temporal temperature decrease (r=−0.049, P=0.751). The mean ± standard deviation preoperative anterior thigh temperature of women who developed temporal hypothermia compared to those who did not was 32.4 ± 0.8°C versus 32.4 ± 0.70°C respectively (P=0.995). Preoperative anterior thigh temperature did not correlate with the incidence of shivering (r=0.267, P=0.080) or thermal comfort scores (r=0.233, P=0.129).ConclusionPreoperative anterior thigh temperature does not correlate with the degree of perioperative temporal temperature decrease, likelihood of developing hypothermia, shivering, or thermal comfort during cesarean delivery with spinal anesthesia. Although core-to-peripheral redistribution of heat after neuraxial anesthesia is a major mechanism of perioperative heat loss, a lower extremity temperature prediction hypothesis was not confirmed in this population.     

Comparative study between ephedrine infusion vs. CO/post loading of fluids for prevention of hypotension in emergency cesarean section under spinal anesthesia

IntroductionMaternal hypotension is the most common complication during cesarean section under spinal anesthesia. The aim of this study was to compare the effectiveness of CO/post loading of fluids versus immediate post spinal infusion of ephedrine in prevention of hypotension.MethodsNinety healthy pregnant patients ASA I with single term fetus arrived to the operating room with nonlife threatening cause for emergency cesarean section under spinal anesthesia. The patients were allocated randomly into 3 groups, Group R: started the CO/post loading at the time of spinal injection and continued after it with 0.5 ml/kg/min Lactated Ringer's solution until delivery of the fetus. Group V: started the CO/post loading with 0.5 ml/kg/min Voluven at the same period. Group E: started ephedrine infusion at 1 mg/min via the infusion pump immediately after spinal anesthesia until delivery of the fetus.ResultsThe systolic blood pressure changes were statistically significant but they failed to reach clinical significant values in the three groups. The total dose of ephedrine was significantly higher in Ephedrine group than the other two groups. Intraoperative heart rate increased in the first 30 min in Ephedrine group without any clinical significance. All fetal data were within normal range and comparable between groups. Apger score of the fetuses was not less than 8 in the three groups. The incidence of nausea and vomiting was higher in group R and group V compared to group E.ConclusionIntravenous infusion of ephedrine 1 mg/min immediately after spinal anesthesia for emergency cesarean sections, even if there is no enough time for proper prehydration, can control effectively the hypotension without episodes of hypertension or significant tachycardia, and it had no effect on fetal well-being. It could be as effective as CO/post loading of 0.5 ml/kg/min lactated Ringer or Voluven in controlling systolic blood pressure with fewer incidences of post operative complications.     

Anestesia durante biópsia muscular para teste de suscetibilidade à hipertermia maligna

IntroductionMalignant hyperthermia is an autosomal dominant pharmacogenetic disorder, characterized by hypermetabolic crisis triggered by halogenated anesthetics and/or succinylcholine. The standard method for diagnosing malignant hyperthermia susceptibility is the in vitro muscle contracture test in response to halothane‐caffeine, which requires muscle biopsy under anesthesia. We describe a series of anesthetic procedures without triggering agents in malignant hyperthermia, comparing peripheral nerve block and subarachnoid anesthesia.MethodWe assessed the anesthetic record charts of 69 patients suspected of malignant hyperthermia susceptibility who underwent muscle biopsy for in vitro muscle contracture in the period of 7 years. Demographic data, indication for malignant hyperthermia investigation, in vitro muscle contracture test results, and surgery/anesthesia/recovery data were analyzed.ResultsSample with 34 ± 13.7 years, 60.9% women, 65.2% of in vitro muscle contracture test positive. Techniques used: peripheral nerve blocks — lateral femoral and femoral cutaneous, latency 65 ± 41 minutes — (47.8%); subarachnoid anesthesia (49.3%), and total venous anesthesia (1.4%). There was 39.4% failure of peripheral nerve block and 11.8% of subarachnoid anesthesia. Adverse events (8.7%) occurred only with subarachnoid blockade (bradycardia, nausea, and transient neurological syndrome). All patients remained in the post‐anesthesia care unit until discharge. Age and weight were significantly higher in patients with blockade failure (ROC cut‐off point of 23.5 years and 59.5 kg) and blockade failure was more frequent in the presence of increased idiopathic creatine kinase.ConclusionAnesthesia with non‐triggering agents has been shown to be safe in patients with malignant hyperthermia susceptibility. Variables such as age, weight, and history of increased idiopathic creatine kinase may be useful in selecting the anesthetic technique for this group of patients.     

Experiencia y tratamiento anestésico en el implante transcatéter de la prótesis valvular aórtica autoexpandible CoreValve®

ObjectiveTo analyze the experience and anesthetic management in the transcatheter implantation of the CoreValve^® self-expanding aortic valve, in a university tertiary hospital.Material and methodsObservational analytical review of data incorporated into a prospectively maintained database of 142 patients diagnosed with severe aortic stenosis who underwent implantation of a CoreValve^® aortic self-expanding aortic valve between December 2007 and December 2012.ResultsThe mean age of patients was 82.5 ± 6.1 years and the logistic EuroSCORE was 14.9 ± 11.2. General anesthesia was used in 107 patients (75.3%), with local anesthesia with sedation in 35 (24.6%). Local anesthesia and sedation was associated with a lower requirement of vasoactive drugs (P = .003) during implantation. No statistically significant differences were found between the 2 anesthetic techniques in the duration of the procedure, hospital stay, or morbimortality. The success rate was 97.1%. The most common complication was conduction disorders that required implantation of a permanent pacemaker in 46 patients (32.3%). There was no intraoperative mortality, and all-cause mortality at 30 days was 6.3%, with a one-year survival estimated by the Kaplan-Meier of 83.1%.ConclusionsThis study confirms that in patients with severe aortic stenosis and high surgical risk, transcatheter implantation of aortic valve is a safe and effective alternative. Both, general anesthesia and local anesthesia with sedation are valid options, depending on the experience of the team.