Epidural anaesthesia for caesarean section in an achondroplastic dwarf

We describe the anaesthetic management of a parturient with achondroplasia presenting for Caesarean section under epidural anaesthesia. A block extending from T4 to S4 was established over 25 min using a total of 12 ml of 2.0% lidocaine (lignocaine) with epinephrine (adrenaline) 1:200,000 and fentanyl 37.5 micrograms. Apart from mild discomfort during peritoneal incision, her perioperative course was uneventful. Achondroplasia is reviewed and the anaesthetic implications of the condition are discussed.      

The extension of epidural blockade for emergency Caesarean section: a survey of current UK practice

The conversion of epidural analgesia during labour to surgical anaesthesia for Caesarean section can have important medical and medicolegal implications. This survey sought to establish the current management for extending epidural blockade for emergency Caesarean section. A postal questionnaire was sent to the lead obstetric anaesthetist in all maternity units in the UK (n = 254). The response rate was 82% (n = 209). Of those surveyed, 68% (136) give the full dose of the local anaesthetic mixture in the delivery room, whilst 12.5% (25) initiate the top-up in the delivery room and give the remainder of the dose in theatre. Fifteen per cent (30) transfer the woman to theatre before commencing anaesthesia and 34% (68) give a test dose before the full anaesthetic dose. Guidelines for converting labour analgesia to anaesthesia for emergency Caesarean section were available in 64% (128) units. Bupivacaine 0.5% was the most commonly used agent, being used as the sole agent by 41.5% (81) units and in combination by a further 18% (36). Adrenaline was added to the chosen local anaesthetic by 30% (60) whilst 12% (24) added bicarbonate. In all, 13 combinations of local anaesthetics and adjuncts were used. The mode time to transfer the patient to theatre was 1 min. Of the 161 respondents who commenced anaesthesia in the delivery room, 71% (114) did not monitor the patient during transfer, whilst 87% (140) had ephedrine immediately available. Thirty-three respondents reported a total of 43 adverse incidents associated with the extension of epidural blockade. These included high blocks, inadequate blocks and possible intravascular injections, the latter resulting in two seizures and one cardiac arrest.     

Anaesthesia in a gravid achondroplastic dwarf

A patient with achondroplasia presented for elective Caesarean section under epidural anaesthesia. A block from C5 to S4 developed over 20 minutes after 12 ml plain bupivacaine 0.5%. This case serves to highlight the difficulties of regional anaesthesia in the gravid achondroplastic dwarf.     

Epidural anaesthesia in von Hippel-Lindau disease

The management of childbirth, including epidural anaesthesia for Caesarean section is described in a patient with von Hippel-Lindau disease. The reasons for the choice of epidural anaesthesia are explained and the anaesthetic significance of the disease is discussed.     

Emergency Caesarean section: best practice

Good multidisciplinary communication is crucial to the safe management of women requiring non-elective Caesarean section. Anaesthetists should participate actively in resuscitation of the fetus in utero; relief of aortocaval compression is paramount. Epidural top-up with levobupivacaine 0.5% is the anaesthetic of choice for women who have been receiving labour epidural analgesia. If epidural top-up fails to provide bilateral light touch anaesthesia from S5 - T5, a combined spinal-epidural technique with small intrathecal dose of local anaesthetic is a useful approach. Pre-eclampsia is not a contra-indication to single-shot spinal anaesthesia, which is the technique of choice for most women presenting for Caesarean section without an epidural catheter in situ. Induction and maintenance doses of drugs for general anaesthesia should not be reduced in the belief that the baby will be harmed. Early postoperative observations are geared towards the detection of overt or covert haemorrhage.     

Anesthesia for emergency cesarean section after uterine rupture associated with recent fracture of the cervical spine

General anaesthesia with intubation is preferable for emergency Caesarean section, whilst epidural anaesthesia should be reserved for elective Caesarean section. The case of a patient who required emergency Caesarean section following uterine rupture is discussed. The management was complicated by a cervical spine injury which had occurred four months previously. Because an epidural catheter had already been inserted at an early stage of labour, this was the anaesthetic technique chosen for the emergency section. This avoided tracheal intubation and the possibility of worsening the cervical fracture. The end result was satisfactory, both for the mother and the child.     

Epidural anaesthesia for Caesarean section in a patient with Devic''s Syndrome

The anaesthetic management of a 29-year-old paraplegic woman suffering from Devic's Syndrome scheduled to undergo Caesarean section under epidural anaesthesia is presented. The case is discussed with particular reference to the risk of autonomic hyperreflexia.     

Anaesthesia for Caesarean section in a patient with Jervell,Lange-Nielsen syndrome

The anaesthetic management of a patient with Jervell, Lange-Nielsen syndrome (a form of congenitally prolonged QT interval) requiring emergency Caesarean section is presented. An epidural anaesthetic using 3-chloroprocaine produced a safe and satisfactory anaesthetic for the procedure in a patient prone to ventricular arrhythmias and cardiac arrest. High levels of circulating catecholamines have been postulated as one of the causes of the arrhythmias in these patients, making it advisable to select drugs and techniques known to minimize catecholamine levels. Although communication can be difficult in these profoundly deaf patients, it is important in order to reduce the emotional stress. Elective Caesarean sections under general anaesthesia have been reported; it appears that a well planned regional anaesthetic is equally safe.     

Successful epidural anaesthesia for a patient with Takayasu’s arteritis presenting for caesarean section

The management of a 24-yr-old parturient with Takayasu’s arteritis (TA) presenting at term for Caesarean section is discussed. The best anaesthetic management for the patient with TA is controversial, but avoiding regional anaesthesia has been suggested by some authors because of the risk of hypotension and the subsequent need for vasopressors. We report the use of regional anaesthesia in a term parturient with severe TA undergoing Caesarean section. Anaesthesia was provided with chloroprocaine 3%, via a lumbar epidural catheter. The initial doses of 60 mg and 150 mg were followed by a decrease in BP (from 110/70 to 70/40) which was corrected with iv fluids and ephedrine 25 mg. Additional doses of chloroprocaine, 150 and 90 mg, were uneventful. It is concluded that an epidural can be made in safety to provide anaesthesia for Caesarean section in patients with TA.     

Effects of volume and concentration of lidocaine on epidural anaesthesia in pregnant females

BACKGROUND AND OBJECTIVE: The effects of altering the concentration of a local anaesthetic on the development of epidural anaesthesia in pregnant females are unclear. We compared the anaesthetic effects of a constant dose of two different concentrations of epidural lidocaine for Caesarean section. METHODS: After Institutional Review Board approval and informed consent, patients undergoing elective Caesarean section were randomized to receive either lidocaine 1% 30 mL (+epinephrine 5 microg mL(-1)) or lidocaine 2% 15 mL (+epinephrine 5 microg mL(-1)) (n = 20 each) for epidural anaesthesia at the L1-L2 interspace. The spread of the sensory block to pinprick and the degree of motor block (modified Bromage scale) were measured at 5, 10, 15, 20 and 30 min after injection. RESULTS: No significant differences in the progression of analgesia and motor block were observed at any time between 1 and 2% lidocaine. The maximum cephalad spread was observed 30 min after injection; the median was at T4 (range T3-T5) and at T4 (range T3-T6) for lidocaine 1 and 2%, respectively. CONCLUSIONS: The same doses but different volumes of lidocaine 1 and 2% produced comparable anaesthetic effects in pregnant females. The effects of epidural anaesthesia depend primarily on the total dose of the local anaesthetic.     

Obstetrical anaesthesia and porphyrias

Acute hepatic porphyrias are genetic diseases, characterized by acute neurological symptoms, sometimes fatal, triggered by different factors, in particular by many anaesthetic drugs, and also by pregnancy. We report here the experience of three porphyric patients'deliveries, allowing us to consider a proposition of management in this context. After discussion between anaesthesiologist, obstetrician and porphyria specialist, two types of management of such patients can be foresee. Asymptomatic patients, or in long remission, can benefit from locoregional anesthesia techniques with bupivacaine for both labour analgesia and Caesarean section. Spinal anaesthesia is then the technique of choice, allowing using smaller quantity of local anaesthetic than epidural anaesthesia. For symptomatic patients, or in crisis, we have rather choose intravenous narcotics for labour analgesia, and general anaesthesia for Caesarean section. The hypnotic agent of choice for both induction and maintenance of such anaesthesia is then propofol.     

Caesarean section in a patient with Cushing's syndrome

Pregnancy is rarely associated with Cushing's syndrome. This case report describes the successful management of a Caesarean section under epidural anaesthesia in a patient with Cushing's syndrome. Maternal and fetal complications are reviewed from an anaesthetic perspective and alternative anaesthetic techniques discussed.     

Combined epidural/spinal anaesthesia for Caesarean section

An evaluation of a 30 gauge spinal needle in a combined epidural/spinal anaesthetic technique for Caesarean section revealed a 25% failure rate of the spinal element. In this unit, no more than 4% of spinal anaesthetics might be expected to fail. One of the reasons for the higher failure rate was that, when using the Tuohy needle as an introducer, the dura was not identified. This prompted us to compare the 'through-the-Tuohy' or needle within needle approach for combined epidural/spinal anaesthesia, with a technique that involved siting the epidural and spinal sequentially in separate spaces. One hundred women requiring elective Caesarean section under spinal anaesthesia were randomised into single or double space groups. The technique failed in 16% of through-the-needle cases, and in 4% of sequential sitings. Combined spinal/epidural anaesthesia for Caesarean section is more successful if each procedure is performed using separate spaces.     

Anaesthesia for Caesarean section in patients with uncontrolled hyperthyroidism

The anaesthetic management of two patients with uncontrolled hyperthyroidism requiring Caesarean section is described. The first patient was diagnosed as hyperthyroid during pregnancy but was resistant to medical management with propylthiouracil (PTU). At 38 weeks' gestation, after optimizing her heart rate with intravenous propranolol, she received an epidural anaesthetic for the Caesarean section. The baby had manifestations of hypothyroidism immediately after birth but later became hyperthyroid. The second patient's hyperthyroidism was well controlled but she stopped her medication one week before delivery. The Caesarean section was performed under general anaesthesia for fetal distress. The baby died in the neonatal period of extreme prematurity. The anaesthetic management of the hyperthyroid parturient is discussed. Preoperative control of hyperthyroidism, bearing in mind pregnancy and time constraints, is essential. The use of PTU, propranolol, iodine, and glucocorticoids is described in the preparation of the parturient. Fetal and neonatal effects of these drugs are discussed.     

Caesarean section in a patient with Cushing’s syndrome

Pregnancy is rarely associated with Cushing’s syndrome. This case report describes the successful management of a Caesarean section under epidural anaesthesia in a patient with Cushing’s syndrome. Maternal and fetal complications are reviewed from an anaesthetic perspective and alternative anaesthetic techniques discussed.     

Anesthesia for cesarean section in a Marfan patient with complicated aortic dissection

We report the anaesthetic management of a 32-year-old pregnant women with aortic dissection and Marfan syndrome for caesarean section. The patient has presented at 31 weeks gestation of a first pregnancy an aortic dissection that required an emergency aortic replacement. Three years later, she presented at 31 weeks gestation with aortic dissection, mitral valve dysfunction and acute pulmonary oedema. She was treated in intensive care unit with deslanoside, diuretic and twice a day echographic examination. Delivery was planned by caesarean section after haemodynamic stabilisation on the sixth day. Combined spinal and epidural anaesthesia was performed after monitoring. The initial intrathecal injection of bupivacaine, morphine and fentanyl provided rapid onset of analgesia. Epidural anaesthesia was used with diluted lidocaine and fentanyl boluses. With appropriate preoperative care and monitoring, uneventful combined spinal and epidural anaesthesia for Caesarean section was achieved in a patient with Marfan syndrome in the presence of aortic dissection complicated by mitral valve dysfunction and acute pulmonary oedema.     

Awake fibreoptic intubation following failed regional anaesthesia for caesarean section in a parturient with Still's disease

The anaesthetic management of a 25-year-old parturient with juvenile rheumatoid arthritis (Still's disease) and a difficult airway presenting for elective Caesarean section is described. Inadequate block after epidural anaesthesia necessitated general anaesthesia. This was safely accomplished by securing the airway with awake oral fibreoptic intubation before general anaesthesia was induced. The problems of performing an awake fibreoptic intubation in a pregnant patient are discussed and a simple method for performing the technique is described.     

The effect of pH adjustment of bupi-vacaine on onset and duration of epidural anaesthesia for Caesarean section

Previous studies have reported that elevation of the pH of local anaesthetics results in more rapid onset of action, with enhanced quality and duration of block. This study investigated the effect of pH adjustment of 0.5 per cent bupivacaine immediately prior to epidural anaesthesia for Caesarean section. Addition of 0.1 ml of 8.4 per cent sodium bicarbonate to 20 ml of 0.5 per cent bupivacaine consistently raised the pH of the local anaesthetic from 5.49 to 7.04 (mean values). One hundred patients, presenting for elective Caesarean section under epidural anaesthesia participated in the study. Forty patients received epidural anaesthesia, using pH-adjusted 0.5 per cent bupivacaine, in a dosage adequate to produce block to the T4 level. A control group of 40 patients received the standard commercial preparation of 0.5 per cent bupivacaine. A further ten patients in each group received epidural anaesthesia using 0.5 per cent bupivacaine with the addition of 1:400,000 epinephrine, to study the effect of epinephrine on pH adjustment of the local anaesthetic. Elevation of the pH of the local anaesthetic significantly increased the speed of onset of action from 6.4 minutes to 3.2 minutes and the time to peak effect from 24.8 minutes to 18.1 minutes, while the duration of anaesthesia was increased from 124.8 minutes to 147.3 minutes. The time to S2 segment blockade was also shortened from 13.5 to 8.6 minutes. Addition of 1:400,000 epinephrine to the local anaesthetic did not influence the effect of pH adjustment. Maternal and umbilical cord plasma levels of bupivacaine were not affected by pH adjustment of the local anaesthetic, while MV/UV and UA/UV ratios were unaltered.     

Ropivacaine 7.5 mg/ml for elective Caesarean section. A clinical and pharmacokinetic comparison of 150 mg and 187.5 mg

Background: The new, long-acting local anaesthetic ropivacaine has shown less systemic toxicity than bupivacaine and a concentration of 7.5 mg/ml can therefore be used for epidural anaesthesia in Caesarean section. The present pilot study was undertaken to find indications for an optimal dosage by comparing the clinical effects, quality of anaesthesia and pharmacokinetics of ropivacaine 150 mg (lower dose=LD) vs 187.5 mg (higher dose=HD) for women undergoing elective Caesarean section under epidural anaesthesia.
Methods: Sixteen full-term women scheduled for elective Caesarean section in two equal-sized consecutive groups received 20 or 25 ml ropivacaine epidurally in this non-randomised, open study. Study parameters included sensory and motor blockade, circulatory response, intraoperative pain and discomfort, neonatal evaluation and pharmacokinetic determinations.
Results: Block height varied between T5 and T2 in the LD group, whereas the HD group produced 4 unnecessarily high blocks (C8 in 3 women and C7 in 1 woman). Surgical anaesthesia was excellent in both groups. Circulatory stability was pronounced in the LD group (no ephedrine given), while 4 women required ephedrine in the HD group. Neonatal outcome as judged by Apgar scores, umbilical blood gas determinations and NACS scores were excellent in both groups. The plasma concentration-time profiles indicated linearity in the concentration range studied, with similar clearance values to those reported previously. Pla-cental drug equilibrium was rapid; however, the foetal drug exposure depended on intrauterine exposure time.
Conclusions: 20–25 ml ropivacaine 7.5 mg/ml produced very satisfactory conditions for elective Caesarean section under epidural anaesthesia. In this small population, 150 mg ropivacaine seemed optimal, while 187.5 mg produced unnecessarily extended block height in 50% of the women.     

Anaesthesia for Caesarean section in a patient with myotonic dystrophy receiving warfarin therapy

A 31-yr-old parturient with myotonic dystrophy and asthma presented for elective Caesarean section. The patient was receiving warfarin having had two previous episodes of thromboembolism. Anticoagulation was subsequently provided by heparin in the weeks prior to delivery. The combination of the patient’s medical conditions and the continuing need for anticoagulation presented a considerable anaesthetic problem in planning anaesthesia and analgesia for both elective and emergency delivery. Heparin was discontinued on the day prior to surgery and restarted immediately after surgery. During surgery flowtron anti-embolitic boots were used. Warfarin therapy was recommenced on the seventh postoperative day. Anaesthesia for Caesarean section was provided using a combined spinal epidural technique using a separate needle, separate interspace method. Postoperative pain was relieved by using a continuous epidural infusion, transcutaneous nerve stimulation and diclofenac. No new neurological problems arose despite the use of epidural analgesia in the presence of heparin anticoagulation. This method of providing anaesthesia and postoperative analgesia without the use of opioids in an anticoagulated, asthmatic, myotonic parturient has not been described elsewhere.