Patient-controlled analgesia following caesarean section under general anaesthesia: a comparison of fentanyl with morphine

This prospective, randomised, double-blind study compared PCA fentanyl with PCA morphine for post-Caesarean section analgesia. Following a standardised general anaesthetic, 37 women were allocated to receive either fentanyl (n = 18) or morphine (n = 19). The PCA was commenced after the women had been made comfortable in the postanaesthetic recovery room with the appropriate opioid solution (mean dose required = fentanyl 375 μg or morphine 16 mg). Initial PCA settings were bolus 1 ml (fentanyl 25 μg or morphine 1 mg), lockout time ten minutes, and no background infusion. Both analgesic solutions provided effective analgesia for a mean of 37 hr with high levels of patient satisfaction, and there were no differences in VAS scores for pain and patient satisfaction, or for side effects (nausea, itch, and sleepiness) between fentanyl or morphine. However, more patients in the fentanyl group required supplementary boluses or alterations to the PCA settings (13/18 vs 4/19: P = 0.005), and one patient was removed from the study due to inadequate analgesia. We conclude that fentanyl is not recommended for routine PCA use following Caesarean section. Cette étude randomisée et à double aveugle compare la PCA au fentanyl avec la PCA à la morphine pour l’analgésie postcésarienne. Après une anesthésie générate standard, 37 femmes sont réparties pour recevoir soil du fentanyl (n = 18) soil de la morphine (n = 19). La PCA est debutée à la salle de réveil des que les patientes se sentent confortables sous une solution appropriée de morphinique (dose moyenne requise, fentanyl 375 μg ou morphine 16 mg). Le régime initial consiste en un bolus d’un ml (fentanyl 25 μg ou morphine 1 mg), un intervalle de sécurité de dix minutes, sans perfusion continue. Les deux solutions produisent une analgésie satisfaisante pour 37 h en moyenne avec un degré élevé de satisfaction pour la patiente, et on ne note pas de différence entre le fentanyl et la morphine pour l’évaluation de la douleur par EVA, le degré de satisfaction, et pour les effets secondaires (nausée, prurit et somnolence). Cependant, plus de patientes sous fentanyl ont eu besoin de bolus supplémentaires ou des modifications aux réglages de la PCA (13/18 vs 4/19; P = 0,005). Une patiente est exclue de l’étude pour raison d’insuffisance d’analgésie. En conclusion, nous ne recommandons pas la PCA au fentanyl après la césarienne.

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Presented at the 1992 meeting of the Society for Obstetric Anesthesia and Perinatology (SOAP) in Charleston, South Carolina, USA.     

Patient-controlled analgesia (PCA) using fentanyl in a parturient with a platelet function abnormality

A term parturient with documented platelet dysfunction presented to the case room for induction of labour. Since this bleeding abnormality contraindicated the use of lumbar epidural analgesia (LEA), we elected to use an iv fentanyl patientcontrolled analgesia (PCA) technique for pain relief during labour. The patient received a 50 μg fentanyl loading dose after which 20 μg boluses of fentanyl were self-administered every three minutes as required. The patient received a total of 400 μg of fentanyl over the 3 1/2 hr of active labour. Mother and neonate tolerated the fentanyl without sequelae. If facilities to monitor the neonate and mother are present, this method of analgesia is useful in those patients where LEA is contraindicated. Au terme d’une grossesse, une patiente porteuse d’une dysfonction plaquettaire devait avoir une induction de travail au bloc obstétrical. Ecartant l’usage d’une epidurale à cause des risques de saignement, nous avons employé du fentanyl en autoanalgésie (PCA) pour soulager les douleurs du travail. Après une dose initiate de50 μg, la patiente s’injectait des doses de 20 μg de fentanyl iv aux 3 minutes prn. Elle utilisa un total de 400 μg de fentanyl au cours des 3,5 heures que dura le travail. La mère et le nouveau-né tolérèrent fort bien ce mode d’analgésie. L’autoanalgésie offre done une alternative au bloc épidural lorsque ce dernier est contre-indiqué toutefois, nous recommandons de monitorer la mére et le nouveau-né pendant quelques heures.     

Propofol anaesthesia in paediatric ambulatory patients: a comparison with thiopentone and halothane

The purpose of this study was to evaluate the haemodynamic changes during induction, as well as the speed and quality of recovery when propofol (vs thiopentone and/or halothane) was used for induction and maintenance of anaesthesia in paediatric outpatients. One hundred unmedicated children, 3–12-yr-old, scheduled for ambulatory surgery were studied. The most common surgical procedures performed were eye muscle surgery (42%), plastic surgery (21%), dental restoration (15%), and urological procedures (15%). The children were randomized to an anaesthetic regimen for induction/maintenance as follows: propofol/propofol infusion; propofol/halothane; thiopentone/halothane; halothane for both induction and maintenance. Succinylcholine 1.5 mg · kg^?1 was used to facilitate tracheal intubation and N₂O/O₂ were used as the carrier gases in each case. All maintenance drugs were titrated according to the clinical response of the patient to prevent movement and/or maintain BP ± 20% of baseline. Two patients (4%) who received propofol expressed discomfort during injection. The mean propofol dose required to prevent movement was 267 ± 83 μg · kg^?1 · min^?1. The overall pattern of haemodynamic changes, as well as awakening (extubation) times were not different among the four groups. Children who received propofol recovered faster (22 vs 29–36 min) (P < 0.05), were discharged home sooner (101 vs 127–144 min) (P < 0.05), and had less postoperative vomiting (4 vs 24–48%) (P < 0.05) than all others. There were no serious complications or adverse postoperative sequelae in any of the patients in the study. It is concluded that induction and maintenance of anaesthesia with propofol is a well-tolerated anaesthetic technique in children, and is associated with faster recovery and discharged as well as less vomiting than when halothane is used.     

Tussive effect of a fentanyl bolus

The aim of this study was to investigate the incidence of pre-induction coughing, after an iv bolus of fentanyl. The study sample was 250 ASA physical status I-II patients, scheduled for various elective surgical procedures. The first 100 were randomly allocated to receive 1.5 micrograms.kg-1 fentanyl via a peripheral venous cannula (Group 1), or an equivalent volume of saline (Group 2). Twenty-eight per cent of patients who received fentanyl, but none given saline, coughed within one minute (P less than 0.0001). The second 150 patients were then randomly assigned to three equal pretreatment groups. Group 3 received 0.01 mg.kg-1 atropine iv one minute before fentanyl. Groups 4 and 5 received 0.2 mg.kg-1 morphine im, and 7.5 mg midazolam po, respectively, one hour before fentanyl. Thirty per cent of patients in Group 3, 6% in Group 4, and 40% in Group 5, had a cough response to fentanyl. Fentanyl, when given through a peripheral cannula, provoked cough in a considerable proportion of patients. This was not altered by premedication with atropine or midazolam, but was reduced after morphine (P less than 0.01). Coughing upon induction of anaesthesia is undesirable in some patients, and stimulation of cough by fentanyl in unpremedicated patients may be of clinical importance.     

Respiratory mechanical properties during fentanyl and alfentanil anaesthesia

The purpose of this study was to assess the effects on respiratory mechanics of fentanyl and alfentanil in 20 subjects to be submitted to coronary artery bypass grafting. Using the end inflation occlusion method (EIOM) we obtained the elastance (E) and resistance (R) of the total respiratory system (_rs), thoracic wall (_w) and lungs (_{L). The total respiratory system was divided into thoracic wall and lungs by using an oesophageal catheter. The data were recorded before, immediately after, and two, five and ten minutes after fentanyl and alfentanil iv bolus, at doses of 30 and 120 μg · kg?I}, respectively. The Ers increased at two, five and ten minutes and the E_L at ten minutes after drug administration. The R_rs,min and R_L,min increased at two, five and ten minutes and the R_L,max at five and ten minutes. Both drugs provoked no change in Ew or Rw. It is concluded that the increases in R_rs.min and R_L.min could be explained by opioid bronchoconstriction. No differences were found between the effects of fentanyl and alfentanil on respiratory mechanics.     

Delayed awakening from general anaesthesia in a patient with Hunter syndrome

Hunter syndrome is one of a heterogeneous group of recessively inherited mucopolysaccharide storage diseases (MPS) with similar biochemical defects manifested by impairments in muco-polysaccharide catabolism with variable but progressive clinical courses. Abnormal accumulation and deposition of mucopoly-saccharides in the tissues of several organs lead to numerous anatomical, musculoskeletal and neurological abnormalities which are known to complicate anaesthetic and airway management. Hunter syndrome has a wide variance of clinical phenotypes ranging from mild to severe. We present a patient having physical and neurological features consistent with a severe clinical presentation of Hunter syndrome (MPS, Type II). Following a seemingly uneventful intraoperative anaesthetic course including isoflurane, nitrous oxide and fentanyl (0.93 μg · kg⁻¹), resumption of spontaneous ventilation and return to consciousness were delayed until intravenous naloxone (200 μg) was administered 100 min after the opioid administration. The cause of delayed recovery from anaesthesia in this patient is unknown. La maladie de Hunter fait partie du groupe des affections hétérogènes héréditaires et récessives des mucopolysaccharidoses (MPS) avec lesquelles elle partage les mêmes anomalies biochimiques. Celles-ci se manifestent par des altérations du catabolisme des mucopolysaccharides et une évolution variable et progressive. L’accumulation anormale de mucopolysaccharides dans les tissus de plusieurs organes provoque de nombreuses lésions musculo-squelettiques et neurologiques qui compliquent la gestion de l’anesthésie et des voies aériennes. Les phénotypes cliniques de la maladie de Hunter varient de légers à graves. Cette observation porte sur un patient qui présente des manifestations cliniques graves de la maladie de Hunter (MPS type II). A la suite d’une anesthésie sans problèmes réalisée avec de l’isoflurane, du protoxyde d’azote, et du fentanyl (0,93 μg · kg⁻¹), le retour normal à la ventilation spontanée et à la conscience est retardé jusqu’à l’administration de naloxone (200 mg) iv effectuée 110 min après le morphinique. La raison de ce retard est inconnue.     

Concentration of fentanyl in colostrum after an analgesic dose

The purpose of this study was to measure the concentration of fentanyl in human colostrum after intravenous administration of an analgesic dose. Thirteen healthy women were given fentanyl 2 micrograms.kg-1 for analgesic supplementation during either Caesarean section or postpartum tubal ligation. Serum and colostrum were collected for 45 min, two, four, six, eight, and ten hours following administration of the drug. Radioimmunoassay showed that colostrum fentanyl concentrations were greatest at 45 min, the initial sampling time, reaching 0.40 +/- 0.059 ng.ml-1, but were virtually undetectable ten hours later. Fentanyl concentrations were always higher in colostrum than in serum. This concluded that with these small concentrations and fentanyl's low oral bioavailability, intravenous fentanyl analgesia may be used safely in breast-feeding women.     

Oral premedication for paediatric ambulatory anaesthesia: a comparison of midazolam and ketamine

Canadian Journal of Anesthesia/Journal canadien d'anesthésie - To compare the clinical characteristics of two oral premedicants, midazolam and ketamine, 40 healthy children, one to six...     

Comparison of perioperative mental function after general anaesthesia and spinal anaesthesia with intravenous sedation

This study compared the postoperative mental function in 44 elderly patients following general anaesthesia (GA) or spinal anaesthesia (SA) with sedation for transurethral resection of prostate. The Mini-Mental State (MMS) was done preoperatively and postoperatively at six hours, one day, three days, five days and one month. The geriatric mental status examination was performed preoperatively and one month after the anaesthetic. There was no significant intergroup difference in the MMS score in the preoperative, six hours, one day, three days, five days and 30 days postoperative scores between the GA and SA with sedation groups. A significant intragroup difference between preoperative and postoperative MMS score was detected in the GA group (P less than 0.02) and in the SA group with sedation (P less than 0.03). In the GA group, the significant decrease in MMS score occurred at 6 h postoperatively (P less than 0.002) whereas in the SA group with sedation, MMS score also decreased significantly at 6 h (P less than 0.005). In conclusion, there was no significant difference in perioperative mental function between the general and spinal anaesthetic groups when supplemental IV sedation was given. In both groups, perioperative mental function decreased significantly at 6 h postoperatively.     

Interactions of preoperative erythromycin administration with general anaesthesia

Previous reports have demonstrated a gastric emptying effect of erythromycin due to a motilin-like mechanism. We studied 50 patients, scheduled for daycase laparoscopy, randomly assigned to one of two groups: Group P patients received 30 min before induction of anaesthesia, in a double-blind manner an infusion of 250 ml dextrose 5% while patients in Group E (n = 25) received 500 mg of erythromycin diluted in 250 ml dextrose 5%. An orogastric tube was inserted to measure both gastric pH using a pHmeter and residual gastric volume (RG V) using the phenol red dilutional technique. Six patients were excluded for surgical reasons. More patients in Group P (6/22) than in Group E (0/22) had RGV > 25 ml and more patients in Group P (17/22) presented with a gastric pH < 2.5 than in Group E (5/22), P < 0.05. Since coma and respiratory depression have been reported recently after midazolam and alfentanil administration in patients having received erythromycin, recovery conditions were assessed and were found to be comparable between groups. In conclusion, the administration of iv erythromycin before outpatient laparoscopy decreased residual gastric volume and increased gastric pH without affecting recovery from general anaesthesia.     

Butorphanol: an opioid for day-care paediatric surgery

The purpose of this study was to compare the side effects and efficacy of equianalgesic doses of morphine (M) and butorphanol (B) in children undergoing similar surgical procedures associated with moderate postoperative pain. We studied 156 healthy children aged 1.5–13 yr who underwent elective inguinal herniorrhaphy or orchidopexy. After induction of anaesthesia subjects were given 150 μg · kg^?1 M or 30 μg · kg^?1 B following a randomized, stratified, blocked and double-blind design. A standardized anaesthetic was administered, which included 1.5% halothane, vecuronium, droperidol and mechanical ventilation. The postsurgical four-hour follow-up included assessment of pain, vomiting and respiratory depression. Pain was assessed with mCHEOPS and analgesics were administered when indicated in the recovery room. Each opioid was administered to a group of 78 patients. Within each group, 25 subjects had an iv induction, 21 children had an orchidopexy and 57 had inguinal hernia repairs. The groups were similar with respect to age, weight, and length of surgery. The choice of opioid did not affect recovery times from anaesthesia. Analgesic requirements were similar among the groups. Ten minutes after arrival in the recovery room the B-subjects had a lower pain score than the M-patients. Postoperative vomiting was less among the B-subjects: 14% vs 28%, P = 0.03. Two M-patients required an unscheduled admission to hospital because of vomiting. It is concluded that butorphanol has few advantages over morphine in the population studied.     

End-tidal carbon dioxide measurement in infants and children during and after general anaesthesia

We have examined the reliability of end-tidal carbon dioxide (PetCO₂) monitoring as an estimate of arterial carbon dioxide tension (PaCO₂) in spontaneously breathing infants and children. Forty patients were studied in the post-anaesthetic care unit; 20 < 12 kg and 20 ≥12 kg. ThePetCO₂ was sampled via a 5 cm 16 gauge catheter taped below an external naris and this measurement was compared with the PaCO₂ of a sample drawn from an indwelling arterial line. Twenty additional patients were studied during inhalational anaesthesia. ThePetCO₂ was measured both from the proximal end of the elbow connector and from a 5 cm cannula inserted through the elbow. An arterial blood gas sample was obtained simultaneously. The arterial to end-tidal (Pa-ET) differences were compared between the two sites. Patients studied in the post-anaesthetic care unit showed good correlation betweenPetCO₂ and PaCO₂ regardless of weight: Pa-EtCO₂ of −0.6 ±3.6 (< 12 kg) and −1.1 ±2.8 mm Hg (≥12 kg). Patients studied during mask anaesthesia showed better correlation betweenPetCO₂ and PaCO₂ whenPetCO₂ was sampled from thte cannula: Pa-ETCO₂ of 3.5 ±4.8 mm Hg (cannula), 8.6 ±4.5 (elbow) (P < 0.05). These results suggest that end-tidal CO₂ monitoring is a useful and reliable method for assessing adequacy of ventilation in spontaneously breathing children weighing between 5.2 and 35 kg. Cette étude vise à évaluer, en ventilation spontanée, la fiabilité du monitorage du CO₂ téléexpiratoire (PetCO₂) comme mesure de la tension du gaz carbonique artériel (PaCO₂) chez des nourrissons et des enfants. Une étude est réalisée d’abord à l’unité des soins postopératoires chez 40 patients: 20 < 12 kg et 20 ≥12 kg. L’échantillonnage de laPetCO₂ se fait par un cathéter 16G de 5 cm fixé sous une narine et la comparaison est établie avec un prélévement artériel. Vingt patients additionnels sont étudiés pendant une anesthésie inhalatoire. LaPetCO₂ est mesurée à la fois à l’extrémité proximate du raccord coudé et par une canule de 5 cm insérée a travers le raccord. (Un échantillon de sang artériel est prélevé simultanément. La différence artério-téléexpiratoire (Pa-ET) est comparée au niveau des deux sites. A l’unité des soins postopératoires, la corrélation entrePetCO₂ et PaCO₂ est bonne et indépendante du poids: Pa-EtCO₂ = −0,6 ±3,6 (< 12 kg) et −1,1 ±2,8 mm Hg (≥12 kg). Pendant l’anesthésie au masque, la corrélation a été meilleure entrePetCO₂ et PaCO₂ quand laPetCO₂ est prélevée par la canule: Pa-EtCO₂ de 3,5 ±4,8 mm Hg (canule), 8,6 ±4,5 (raccord) (P < 0,05). Ces résultats suggèrent que le monitorage du CO₂ téléexpiratoire est utile et liable pour évaluer la suffisance de la ventilation chez des enfants pesant de 5,2 à 35 kg.

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Presented in part at The Canadian Anaesthetists’ Society Annual Meeting, Quebec City, 1991.     

Low-dose sufentanil and lidocaine supplementation of general anaesthesia

This randomized double-blind study compared the effects of: (1) saline infusion (C); (2) sufentanil alone (1.0 micrograms.kg-1) (S); and (3) low-dose sufentanil (0.5 micrograms.kg-1) in combination with lidocaine (1.5 mg.kg-1) (LS): on the cardiovascular responses to tracheal intubation and on postoperative ventilation as monitored by respiratory inductive plethysmography in day-care surgical procedures of approximately 60 min duration. Thirty healthy, unpremedicated patients were studied. Thiopentone requirements were reduced by 40 and 28 per cent in the S and LS groups respectively compared with control (P less than 0.001). Both treatments suppressed HR and BP responses (P less than 0.005) to intubation. Postoperatively, PaCO2 was elevated (P less than 0.05) in group S. Dose-related respiratory depression was observed. The incidence of postoperative apnoea was significantly higher in both S and LS groups than compared with control (P less than 0.05). However, only patients in group S showed higher apnoea index and mean apnoea duration over the initial 10-20 min after surgery compared with control (P less than 0.005). In addition, group S showed slower respiratory frequency and prolonged expiratory time (P less than 0.005). In conclusion, an induction dose of sufentanil (1 microgram.kg-1) used in balanced anaesthesia of less than 70 min duration was associated with significant respiratory depression, particularly during the initial 10-20 min after surgery, whereas low-dose sufentanil (0.5 micrograms.kg-1) with lidocaine (1.5 mg.kg-1) had minimal postoperative respiratory depression and comparable attenuation of pressor responses to intubation.     

Recall of intraoperative events after general anaesthesia and cardiopulmonary bypass

We wished to identify patients able to recall intraoperative events after general anaesthesia involving cardiopulmonary bypass (CPB). A balanced anaesthetic technique consisting of benzodiazepines, low dose fentanyl (15.9 ± 8.5 μg· kg^{− 1}) and a volatile agent was employed. Perioperative recall was sought utilizing a structured interview on the fourth or fifth postoperative day. During 20 mo 837 patients underwent CPB. Seven hundred patients (84%) were able to respond to a structured postoperative interview. A detailed chart review was performed in patients with recall and in 60 randomly selected patients without recall. Eight patients (1.14%) reported recall of intraoperative events. We were unable to identify any differences between the two groups with respect to narcotic, benzodiazepine dosage or usage of inhalational agents. The incidence of recall in patients undergoing cardiac surgery was less in our group than previously reported. It is, however, higher than the 0.2% incidence recently reported in patients undergoing non-cardiac surgery. This is probably due to patient characteristics and intraoperative factors which make it difficult to avoid periods of relatively light anaesthesia during cardiac surgery. L’objectif de ce travail est d’identifier les patients capables de se rappeler des événements survenus pendant la chirurgie sous circulation extracorporelle (CEC). L’anesthésie consiste en des benzodiazépines, du fentanyl à faibles doses (15,9 ± 8,5 μg· kg^{− 1}), et un agent volatile. On recherche la mémoire évocative périopératoire lors d’une interview au quatrième ou cinquième jour postopératoire. Sur une période de 20 mois, 837 patients ont subi une CEC. De ceux-ci, 700 (84%) sont capables de répondre à une interview postopératoire. Une révision du dossier d’anesthésie est effectuée chez les patients avec mémoire évocative et chez 60 patients sans mémoire évocative. Huit patients (1,14%) se rappellent certains événements périopératoires. Il n’y a pas de différence entre les deux groupes au regard de la posologie opiacée, des benzodiazépines ou de la concentration anesthésique. L’incidence de la mémoire évocative chez nos patients de chirurgie cardiaque est moindre que celle d’études antérieures. Elle est toutefois plus élevée que l’incidence de 0,2% récemment rapportée chez des patients de chirurgie autre que cardiaque. Selon toute probabilité, cette différence est due aux caractéristiques des malades et à des facteurs peropératoires qui ne permettent pas d’éviter pendant la chirurgie cardiaque des périodes d’anesthésie légère.

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Presented in part at the Canadian Anaesthetists’ Society 49th Annual Meeting in Toronto, June 1992.     

Isoflurane compared with nitrous oxide anaesthesia for intraoperative monitoring of somatosensory-evoked potentials

Intraoperative monitoring of somatosensoryevoked potentials is a routine procedure. To determine the depressant effect of nitrous oxide relative to isoflurane, the authors recorded the scalp, cervical and brachial plexusevoked responses to stimulation of the median nerve under different anaesthetic conditions. Eight subjects, age 35 ± 6 (SD) yr, weight 68 ± 12 kg, were studied. Following recording of awake control responses, anaesthesia was induced with thiopentone 5 mg· kg^{? 1} and fentanyl 3 μg· kg^{? 1} and was followed by succinylcholine 1 mg· kg^{? 1}. During normocapnia and normothermia, and with a maintenance infusion of fentanyl 3 μg · kg^{? 1}· hr^{? 1}, evoked potential recording was repeated under three different anaesthetic conditions; 0.6 MAC nitrous oxide, 0.6 MAC nitrous oxide ± 0.6 MAC isoflurane, and 0.6 MAC isoflurane. Among the anaesthetic conditions, the combination of nitrous oxide-isoflurane had the most depressant effect on the cortical amplitude (67 ± 4% reduction, P < 0.05). Nitrous oxide decreased the cortical amplitude more than an equipotent dose of isoflurane (60 ± 4% vs 48 ± 7%, P < 0.05). The latency was unchanged by nitrous oxide, but increased slightly by isoflurane and isofluranenitrous oxide anaesthesia (1.0 and 0.9 msec respectively, P < 0.05). We conclude that somatosensory-evoked potential monitoring is feasible both during nitrous oxide anaesthesia and isoflurane anaesthesia, but the cortical amplitude is better preserved during 0.6 MAC of isoflurane alone relative to 0.6 MAC of nitrous oxide alone. The depressant effect is maximal during nitrous oxideisoflurane anaesthesia but less than the predicted additive effect.     

Regional anaesthesia for hernia repair in children: local vs caudal anaesthesia

The purpose of this study was to compare the effect of local anaesthesia (LA) with that of caudal anaesthesia (CA) on postoperative care of children undergoing inguinal hernia repair. This was a randomized, single-blind investigation of 202 children aged 1–13 yr. Anaesthesia was induced with N₂O/O₂ and halothane or propofol and maintained with N₂O/O₂/halothane. Local anaesthesia included ilioinguinal and iliohypogastric nerve block plus subcutaneous injection by the surgeon of up to 0.3 ml · kg^?1 bupivacaine 0.25% with 5 μg · kg^?1 adrenaline. The dose for caudal anaesthesia was 1 ml · kg^?1 up to 20 ml bupivacaine 0.2% with 5 μg · kg^?1 adrenaline. Postoperative pain was assessed with mCHEOPS in the anaesthesia recovery room, with postoperative usage of opioid and acetaminophen in the hospital, and with parental assessment of pain with a VAS. Vomiting, time to first ambulation and first urination were recorded. The postoperative pain scores and opioid usage were similar; however, the LA-group required more acetaminophen in the Day Care Surgical Unit. The incidence of vomiting and the times to first ambulation and first urination were similar. The LA-patients had a shorter recovery room stay (40 ± 9 vs 45 ± 15 min, P < 0.02). The postoperative stay was prolonged in the CA group (176 ± 32 vs 165 ± 26 min, P = 0.02). We conclude that LA and CA have similar effects on postoperative care with only slight differences.     

Continuous regional anaesthesia in infants

Physiological immaturity of the respiratory musculature and central respiratory control centres leads to an increased risk of apnoea and respiratory complications following general anaesthesia in neonates. Regional anaesthetic techniques may obviate the need for general anaesthesia and lessen the risks of perioperative morbidity. Although these techniques have been described in infants, previous reports have dealt with singleshot techniques for brief surgical procedures (< 60 min). Experience with prolonged operative cases using regional anaesthesia via indwelling catheters in infants is limited. We present our experience with four infants in whom either caudal epidural or spinal anaesthesia was administered via indwelling catheters for operative procedures that lasted 90 to 180 min. We believe this technique is an alternative to general anaesthesia in these patients. A cause de l’immaturité physiologique de sa musculature et de son centre respiratoires, le nouveau-né est plus sujet à l’apnée et aux complications après une anesthésie générale. L’anesthésie régionale peut remplacer en partie l’anesthésie générale et diminuer ainsi la morbidité périopératoire. Les techniques régionales sont bien décrites pour l’enfant mais elles sont utilisées en doses uniques pour des interventions brèves (< 60 min). L’expérience d’interventions sous régionale avec des cathéters en place est limitée. Nous présentons ici notre expérience avec quatre enfants auxquels on a administré une caudale ou une rachianesthésie continue pour des interventions de 90 à 180 min. Nous croyons que ces techniques sont des alternatives valables à l’anesthésie générale chez ces patients.     

Comparison of endocrinological stress response associated with transvaginal ultrasound-guided oocyte pick-up under halothane anaesthesia and neuroleptanaesthesia

Twelve patients with mechanical infertility in the in vitro fertilization program were studied. Seven of them received halothane anaesthesia and the other five received neuroleptanaesthesia. Higher plasma prolactin levels and lower plasma progesterone levels were observed in the neuroleptanaesthesia group than in the halothane group during and after transvaginal ultrasound-guided oocyte pick-up. Plasma adrenocorticotropic hormone and cortisol levels of the patients suggested that surgical stress was minimal in both groups. It is likely that droperidol and fentanyl, both used in neuroleptanaesthesia, were responsible for the hyperprolactinaemia which was followed by inhibition of progesterone production. These agents, therefore, are not recommended as anaesthetic agents for transvaginal ultrasound-guided oocyte pick-up.     

Obstetrical anaesthesia for patients with the syndrome of haemolysis,elevated liver enzymes and low platelets

The syndrome of haemolysis, elevated liver enzymes and low platelets (HELLP Syndrome) is a consequence of severe preeclampsia/eclampsia. The clinical course is characterized by an unusual presentation with abdominal pain, and manifestations of inadequate haemostasis and excessive bleeding are common. Maternal and perinatal morbidity and mortality are high. We report our experience with 33 patients over a five-year period. The mean gestational age (GA) of the pregnancies was 34 +/- 2.8 wk including 11 patients who delivered 12 neonates of less than 34 wk GA. The most common presenting complaints were right upper quadrant or epigastric pain in 25 patients (76%) and nausea or vomiting in 14 patients (42%). Diagnosis was missed or delayed in 12 patients (36%). Thirty-one patients (94%) were delivered by Caesarean section and a deteriorating maternal condition was the most common indication for operative delivery. Twenty-three patients received general anaesthesia, eight received epidural anaesthesia and there were no complications related to the anaesthetic. There was clinical evidence of abnormal haemostasis: seven patients had excessive blood loss at Caesarean section, two had postpartum haemorrhage, three developed DIC and four developed wound haematoma. The average decrease in haemoglobin concentration was 32 g.L-1 and twelve patients (36%) received blood transfusions. There was one stillbirth. There were no neonatal deaths but morbidity was prominent and related primarily to prematurity. Delayed or missed diagnosis is common in HELLP syndrome and a premature delivery by Caesarean section is usual.(ABSTRACT TRUNCATED AT 250 WORDS)     

A comparative study of patient-controlled epidural fentanyl and single dose epidural morphine for post-caesarean analgesia

In a prospective, randomized, double-blinded study, 23 patients who had undergone Caesarean delivery under epidural anaesthesia were assessed to evaluate the effectiveness of patientcontrolled epidural analgesia (PCEA) with fentanyl compared with a single dose of epidural morphine for postoperative analgesia. Group A (n = 11) received epidural fentanyl 100 μg intraoperatively, then self-administered a maximum of two epidural fentanyl boluses 50 μg (10 μg · ml^?1) with a lockout period of five minutes for a maximum of two doses per hour. Group B (n = 11) received a single bolus of epidural morphine 3 mg (0.5 mg · ml^?1) intraoperatively and received the same instructions as Group A but had their PCA devices filled with 0.9% NaCl. Patients were assessed up to 24 hr for pain, satisfaction with pain relief, nausea and pruritus using visual analogue scales (VAS). The treatments for inadequate analgesia, nausea and pruritus as well as time to first independent ambulation were recorded. The ventilatory response to carbon dioxide challenge was measured at four and eight hours. Pain relief, satisfaction with pain relief, and the use of supplemental analgesics were similar in both groups. The mean 24 hr dose of epidural fentanyl used by group A patients was 680 μg. Pruritus was less common in Group A patients at the 8 and 24 hr observation periods (P < 0.0125). Both groups experienced the same degree of nausea and clinically unimportant respiratory depression. We conclude that PCEA with fentanyl provides analgesia equal to a single dose of epidural morphine and may be suitable for patients who have experienced considerable pruritus after epidural morphine adminstration.