Prevention of postoperative nausea and vomiting after spinal morphine for Caesarean section: comparison of cyclizine,dexamethasone and placebo

Background. Low-dose intrathecal (spinal) morphine (0.1–0.2mg) for Caesarean section delivers excellent postoperative analgesiabut is associated with significant nausea and vomiting. We comparedthe antiemetic efficacy of cyclizine, dexamethasone, and placeboin this clinical setting. Methods. Ninety-nine women undergoing elective Caesarean sectionunder spinal anaesthesia were allocated randomly, in a double-blindstudy design, to receive either cyclizine 50 mg, dexamethasone8 mg, or placebo as a single-dose infusion in saline 0.9%, 100ml on completion of surgery. Spinal anaesthesia consisted of:hyperbaric bupivacaine 0.5%, 2.0 ml; fentanyl 10 µg; andspinal morphine 0.2 mg. The primary outcome measure was theincidence of nausea. Results. The incidence of nausea was significantly less in patientsreceiving cyclizine compared with dexamethasone and placebo(33 vs 60 and 67%, respectively, P<0.05). Severity of nauseaand number of vomiting episodes were also less at 3–6h in cyclizine patients. Overall satisfaction with postoperativecare at 24 h, expressed on a 100 mm visual analogue scale, wasgreater in cyclizine [78 (28)] than either dexamethasone [58(31), P=0.03] or placebo [51 (28), P=0.008]. Conclusion. We conclude that following spinal morphine 0.2 mgand fentanyl 10 µg analgesia for Caesarean section, cyclizine50 mg i.v. reduces the incidence of nausea compared with dexamethasone8 mg i.v. or placebo. It also lessens the severity of nauseaand vomiting, and increases maternal satisfaction in the earlypostoperative period. Br J Anaesth 2003; 90: 665–70     

Epidural versus intrathecal morphine for postoperative analgesia after Caesarean section

Background. Perispinal anaesthesia for Caesarean section allowsinjection of epidural (ED) or intrathecal (i.t.) morphine toprovide long-lasting postoperative analgesia. To compare thesetwo routes, a prospective, randomized, double-blinded studyof 53 patients undergoing elective Caesarean section was performed. Methods. Combined spinal-epidural anaesthesia with 6 mg of i.t.hyperbaric bupivacaine plus sufentanil 5 µg, and additionalED lidocaine was used. Additionally, each patient received either2 mg (2 ml) of ED morphine plus 1 ml of i.t. normal saline (EDgroup, n=28), or 0.075 mg (1 ml) of i.t. morphine plus 2 mlof ED normal saline (i.t. group, n=25). Additional postoperativeanalgesia was given in the form of propacetamol and ketoprofen,plus self-administered i.v. morphine. Results. No major respiratory depression occurred. Time to firstdemand of morphine was similar in the ED (307.5 min) and i.t.(310 min) groups, as was the incidence of side-effects suchas sedation, pruritis, nausea, and vomiting. During the first24 postoperative hours, VAS pain scores were greater in thei.t. group (P=0.032), as was additional morphine consumption(4 vs 1.5 mg) (P=0.03). Conclusions. The ED protocol was more effective than the i.t.protocol, whilst side-effects were similar. Br J Anaesth 2003; 91: 690–4     

Dextromethorphan and intrathecal morphine for analgesia after Caesarean section under spinal anaesthesia

Background. Dextromethorphan is an N-methyl-D-aspartic acidantagonist which can attenuate acute pain with few side-effects.In this prospective, randomized, double-blind study of dextromethorphanand intrathecal morphine, we investigated postoperative pain,pruritus, nausea and vomiting in women undergoing Caesareansection under spinal anaesthesia. Methods. Women were allocated randomly to one of six groups,to receive intrathecal morphine 0.05, 0.1 or 0.2 mg plusoral dextromethorphan 60 mg or placebo. Results. The addition of dextromethorphan did not reduce postoperativepain scores (P=0.83). Compared with women receiving intrathecalmorphine 0.05 mg, women receiving higher doses had a significantlyhigher incidence of nausea and vomiting [odds ratio for intrathecalmorphine 0.1 mg, 4.0 (95% confidence interval 1.2–14.1);for intrathecal morphine 0.2 mg, 7.9 (2.3–27.1)].Compared with women receiving intrathecal morphine 0.05 mg,women receiving higher doses also had a significantly higherincidence of pruritus [odds ratio for intrathecal morphine 0.1 mg,3.2 (95% confidence interval 1.3–8.2); for intrathecalmorphine 0.2 mg, 3.7 (1.4–9.5)]. Women receivingdextromethorphan had a lower incidence of nausea and vomiting[odds ratio 2.6 (1.1–6.3)]. Conclusions. Postoperative pain after Caesarean section underspinal anaesthesia was not reduced by the addition of oral dextromethorphanto a multimodal approach including intrathecal morphine. Br J Anaesth 2003; 90: 653–8     

Effects of intraoperative i.v. acetaminophen vs i.m. meperidine on post-tonsillectomy pain in children

Background. Enteral acetaminophen, when used alone, is not veryeffective for postoperative analgesia because of delayed absorptionand sub-therapeutic plasma concentrations. In contrast, i.v.acetaminophen is devoid of these shortcomings and could potentiallyprovide adequate postoperative analgesia as a single agent.This randomized double-blind study compared the analgesic effectsof i.v. acetaminophen and i.m. meperidine in paediatric patientsundergoing tonsillectomy. Methods. Eighty children undergoing tonsillectomy were randomizedto receive either acetaminophen 15 mg kg^–1 i.v. (acetaminophengroup) or meperidine 1 mg kg^–1 i.m. (meperidine group),intraoperatively. Anaesthesia was induced with either sevofluraneinhalation or propofol, and was maintained with sevoflurane.After operation, the objective pain scale (OPS), Ramsay sedationscore and Aldrete score were recorded every 5 min, and nurses'satisfaction was determined on a 7-point scale (1–7). Results. On admission to the recovery room, OPS scores were3.1 (SEM 0.3) for the acetaminophen group and 2.1 (SEM 0.3)for the meperidine group (P=0.147); however, Ramsay sedationscores were 3 (SEM 0.2) and 4 (SEM 0.3) for the acetaminophenand meperidine groups, respectively (P<0.05). Patients inthe meperidine group continued to be more sedated 5 min afterarrival in recovery (P<0.05). Acetaminophen group patientsachieved an Aldrete score of 10 min sooner than those in themeperidine group [median (IQR) time: 15 (0–20) min vs25 (15–30) min, respectively, P=0.005]. Adjusted nursesatisfaction scores were similar in both groups [6.1 (SEM 0.2)vs 5.7 (SEM 0.2) min, P=0.311]. Conclusion. Compared with i.m. meperidine, i.v. acetaminophenprovided adequate analgesia, less sedation and earlier readinessfor recovery room discharge among paediatric patients undergoingtonsillectomy.     

The effect of addition of intrathecal clonidine to hyperbaric bupivacaine on postoperative pain and morphine requirements after Caesarean section: a randomized controlled trial

Background. Intrathecal clonidine prolongs spinal anaesthesia.We investigated the effect of the addition of clonidine (75µg) to hyperbaric bupivacaine on postoperative morphineconsumption after Caesarean section in a randomized controlleddouble-blind trial. Methods. A group of 106 women received spinal anaesthesia usingeither bupivacaine 0.5% (2.2 ml) heavy with 0.5 ml normal saline0.9% (B) or bupivacaine 0.5% (2.2 ml) heavy with clonidine (75µg) in 0.5 ml normal saline 0.9% (BC). The primary outcomewas the total morphine consumption in the first 24 h after surgery.Secondary outcomes were the duration of postoperative analgesia,postoperative pain scores, the need for alfentanil during surgery,block regression, clonidine side-effects and morphine side-effects. Results. Total morphine consumption was similar in both studygroups. The mean time to the first analgesic request in theBC group was 129 (SD 13.8) min, compared with 55 (14.2) minin the B group [mean difference (95% CI) –75 (–106to –44) min]. In the BC group 22 (42%) patients had acomplete motor block 1 h after surgery compared with 4 (8%)patients in the B group [RR (95% CI) 0.18 (0.07–0.49)].Side-effects of intrathecal clonidine were not detected. Conclusions. The addition of clonidine (75 µg) to hyperbaricbupivacaine prolongs spinal anaesthesia after Caesarean sectionand improves early analgesia, but does not reduce the postoperativemorphine consumption during the first 24 h. No clinically relevantmaternal or neonatal side-effects were detected.     

Comparison of intrathecal fentanyl and diamorphine in addition to bupivacaine for caesarean section under spinal anaesthesia

Background. Co-administration of small doses of opioids andbupivacaine for spinal anaesthesia reduces intraoperative discomfortand may reduce postoperative analgesic requirements in patientsundergoing Caesarean section. Fentanyl and diamorphine are thetwo most frequently used agents in UK obstetric anaestheticpractice. Methods. Seventy-five healthy parturients scheduled for electiveCaesarean section under spinal anaesthesia using hyperbaric0.5% bupivacaine, were randomly allocated to additionally receiveintrathecal fentanyl 20 µg, diamorphine 300 µg or0.9% saline. Patients also received i.v. cyclizine and rectaldiclofenac. Results. Less supplementary intraoperative analgesia was requiredby patients in either opioid group (4%) compared with the control(32%) (P<0.05). Twenty four hours after spinal injection,total mean (SD) postoperative morphine requirement was significantlylower if diamorphine was administered (31 (21) mg), in comparisonwith the other two groups (control 68 (26) mg; fentanyl 62 (26)mg) (P<0.05). Reduced visual analogue pain scores were evident12 h following diamorphine, but observed only for 1 h afterfentanyl when compared with the control (P<0.05). Mild pruritiswas more common for 2 h after either spinal opioid (P<0.05),but no inter-group differences were observed for the remainderof the first 24 h. Patients displayed deeper levels of sedationboth acutely and 12 h after administration of intrathecal fentanyl(P<0.05). Conclusions. Both intrathecal opioids reduce intraoperativediscomfort, but only diamorphine reduced postoperative analgesicrequirement beyond the immediate postoperative period. Br J Anaesth 2002; 89: 452–8     

Intrathecal morphine and clonidine for coronary artery bypass grafting

Background. After cardiac surgery adequate postoperative analgesiais necessary. We assessed analgesia using intrathecal morphineand clonidine. Methods. In a double-blind randomized study, 45 patients havingcoronary artery bypass graft surgery were allocated randomlyto receive i.v. patient-controlled analgesia (PCA) morphine(bolus, 1 mg; lock-out interval, 7 min) (control group), eitheralone or combined with intrathecal morphine 4 µg kg^–1or with both intrathecal morphine 4 µg kg^–1and clonidine 1 µg kg^–1. Intrathecal injectionswere performed before the induction of general anaesthesia.Pain was measured after surgery using a visual analogue scale(VAS). We recorded i.v. PCA morphine consumption during the24 h after operation. Results. Morphine dosage [median (25th–75th percentiles)]was less in the first 24 h in the patients who were given intrathecalmorphine + clonidine [7 (0–37) mg] than in other patients[40.5 (15–61.5) mg in the intrathecal morphine group and37 (30.5–51) mg in the i.v. morphine group]. VAS scoreswere lower after intrathecal morphine + clonidine compared withthe control group. Time to extubation was less after intrathecalmorphine + clonidine compared with the i.v. morphine group [225(195–330) vs 330 (300–360) min, P<0.05]. Conclusion. Intrathecal morphine and clonidine provide effectiveanalgesia after coronary artery bypass graft surgery and allowearlier extubation. Br J Anaesth 2003; 90: 300–3     

Evaluation of S1 motor block to determine a safe,reliable test dose for epidural analgesia

Background. Accidental intrathecal injection of bupivacaineduring epidural analgesia in labour remains a hazard, with thepotential to cause total spinal anaesthesia and maternal collapse.Sacral block appears early after intrathecal injections comparedwith epidural ones, and we therefore used S1 motor block todetermine a safe and reliable test dose for epidural cathetermisplacement. Methods. Mothers booked for elective Caesarean section weregiven various intrathecal doses of bupivacaine with fentanylduring routine combined spinal–epidural anaesthesia. Results. Using sequential allocation we found that the ED₅₀for S1 motor block 10 min after intrathecal injection was bupivacaine7 mg with fentanyl 14 µg (95% CI, 6.2–7.8 mg). Wethen used intrathecal bupivacaine 13 mg to look for the ED₉₅.We found the calculated ED_97.5 to be bupivacaine 9.7 mg withfentanyl 19.4 µg (95% CI, 8.7–11.4). Conclusion. We conclude that testing for S1 motor block 10 minafter epidural injection of bupivacaine 10 mg is a reliabletest to detect accidental intrathecal injection in the obstetricpopulation. Br J Anaesth 2002; 88: 442–5     

Motor block during patient-controlled epidural analgesia with ropivacaine or ropivacaine/fentanyl after intrathecal bupivacaine for caesarean section

We compared patient-controlled epidural analgesia (PCEA) withropivacaine alone or combined with fentanyl in terms of analgesicefficacy, motor weakness and side-effects in patients who hadreceived spinal anaesthesia for elective Caesarean section.ASA I patients received combined spinal–epiduralanaesthesia and were randomly assigned, in a double-blind study,into two groups after operation: group R (n=23) received PCEAropivacaine 0.1%, bolus 5 mg, lockout 15 min, 3 mg h^–1background infusion, and group RF (n=24) received PCEA 0.1%ropivacaine/fentanyl 2 µg ml^–1 at identicalsettings. Pain and satisfaction on a 100 mm visual analoguescale (VAS) and side-effects were noted. Incidence of motorweakness (Bromage grade 1 or higher) was 48% (11/23) at8 h in group R compared with 13% (3/24) in group RF (P=0.025). Painscores on movement were lower in group RF at 8 and 12 hand at rest at 6 and 8 h (P<0.05 for each comparison).Analgesic consumption was less in RF (P=0.041), but there wasno difference in time to first request for supplementary analgesia.Patient satisfaction with postoperative analgesia (mean (SD))was higher in RF (79 (23) vs 57 (29) mm, P=0.045).Caution should be exercised using ropivacaine PCEA after spinalbupivacaine for Caesarean section, because its reputed motor-sparingproperty may be unreliable. Br J Anaesth 2000; 85: 468–70 ^* Corresponding author: University Department of Anaesthesia,Leicester General Hospital, Leicester LE5 4PW, UK     

Randomized controlled study of colloid preload before spinal anaesthesia for caesarean section

We randomized women having elective Caesarean section to receiveeither no preload (control group, n=33) or 4% gelatin solution(Gelofusine) 15 ml kg^–1 (colloid group, n=35)i.v. before spinal anaesthesia. Intravenous metaraminol wastitrated at 0.25–0.75 mg min^–1 to maintainsystolic arterial pressure (SAP) in the target range 90–100%of baseline after the spinal injection. The control group requiredmore vasopressor in the first 10 min [median 1.7 (range 0–2.9)mg vs 1.4 (0–2.8), P=0.02] at a greater maximum infusionrate [0.5 (0–0.75) vs 0.25 (0–0.5) mg min^–1,P=0.0005] and had a lower minimum SAP [90 (51–109) vs101 (75–127) mm Hg, P=0.006] than the colloid group. Nauseawas less frequent in the colloid group (6 vs 24%) but neonataloutcome was similar in the two groups. Colloid preload improvedhaemodynamic stability but did not affect neonatal outcome whenarterial pressure was maintained with an infusion of metaraminolduring spinal anaesthesia for Caesarean section. Br J Anaesth 2001; 87: 772–4     

Choice of opioid for initiation of combined spinal epidural analgesia in labour--fentanyl or diamorphine

Sixty-two women requesting regional analgesia in labour wereallocated to receive a 1.5 ml intrathecal injection aspart of a combined spinal–epidural (CSE) analgesic technique.This contained either bupivacaine 2.5 mg plus fentanyl25 µg (group F) or bupivacaine 2.5 mg plus diamorphine250 µg (group D). Times of analgesic onset and offsetwere recorded, motor and proprioceptive assessments made andside-effects noted. Analgesic onset was not significantly differentbetween the groups (group F, 8.0 min; group D, 9.5 min; P=0.3)but time to first top-up request was significantly longer inthe diamorphine group (group F, 73 min; group D, 101 min; P=0.003).Motor loss, assessed by the modified Bromage score, was statisticallybut not clinically greater in the fentanyl group (P=0.01). Maternalhypotension, pruritis, proprioceptive loss, nausea and fetalbradycardia were rare and not severe, and their incidences didnot differ between groups. No respiratory depression was observedafter CSE. This use of diamorphine was not associated with increasedside-effects compared with fentanyl/bupivacaine, and it hasa longer duration of action. Br J Anaesth 2001; 86: 567–9     

Epidural test dose with levobupivacaine and ropivacaine: determination of ED(50) motor block after spinal administration

Background. When a test is required to detect a possible intrathecalcatheter, many would seek to use the same local anaestheticas that used for epidural analgesia. The rapid onset of inappropriatemotor block after a local anaesthetic administered epidurallyimplies intrathecal spread. Because of claims of greater sensory–motorseparation, or because of reduced potency compared with bupivacaine,the efficacy of the new local anaesthetics in intrathecal testinghas been questioned. The aim of this study was to establishthe feasibility of a test dose for an inadvertent intrathecalcatheter using ropivacaine and levobupivacaine, and to establishthe dose required. Methods. Sixty women undergoing elective Caesarean section witha combined spinal– epidural technique were enrolled intothis prospective, double-blind sequential allocation study.The women were randomized to receive plain levobupivacaine 0.5%or ropivacaine 0.5% intrathecally. The dose was determined accordingto up–down sequential allocation. The end-point was anyevidence of lower limb motor block within 5 min of injection. Results. The ED₅₀ motor block at 5 min was 4.8 mg (95% CI, 4.49,5.28) for levobupivacaine and 5.9 mg (95% CI, 4.82, 6.98) forropivacaine (95% CI difference, 0.052, 1.98) (P=0.04). The estimatedED₉₅ motor block was 5.9 mg (95% CI 5.19, 6.71) for levobupivacaineand 8.3 mg (95% CI, 6.30, 10.44) for ropivacaine. The potencyratio between the two drugs was 0.83 (95% CI, 0.69, 0.99). Conclusions. Both local anaesthetics produce evidence of motorblock within 5 min of intrathecal injection and could serveas tests of intrathecal administration. Derived ED₉₅ valuessuggest 10 mg doses should be effective, but this study didnot measure predictive value. Ropivacaine is less potent formotor block than levobupivacaine by a factor of 0.83 (P<0.04). Br J Anaesth 2004; 92: 850–3     

Intrathecal midazolam increases the analgesic effects of spinal blockade with bupivacaine in patients undergoing haemorrhoidectomy

In the present double-blind study we aimed to evaluate the postoperativeanalgesic effects of intrathecal midazolam with bupivacainefollowing haemorrhoidectomy. Forty-five patients were randomlyallocated to one of three groups: the control group received1 ml of 0.5% heavy bupivacaine plus 0.2 ml of 0.9% saline intrathecally,group BM1 received 1 ml of 0.5% bupivacaine plus 0.2 ml of 0.5%preservative-free midazolam and group BM2 received 1 ml of 0.5%bupivacaine plus 0.4 ml of 0.5% midazolam. Time to first analgesiawas significantly greater in the midazolam groups than in theplacebo and significantly less in the BM1 group than in theBM2 group. Br J Anaesth 2001; 86: 77–9     

Effect of intrathecal diamorphine on block height during spinal anaesthesia for Caesarean section with bupivacaine

Background. Opioid analgesics are commonly added to intrathecalbupivacaine to improve patient comfort during Caesarean sectionunder spinal anaesthesia, and provide post-operative pain relief.We sought to discover if the addition of diamorphine influencedblock height when given with 0.5% w/v hyperbaric bupivacaine. Method. Eighty ASA I and II women of at least 37 weeks gestationand planned for elective Caesarean section under combined spinal–epiduralanaesthesia were recruited. They were randomized into two groupsto receive intrathecal hyperbaric bupivacaine 0.5% at an initialdose of 13 mg, with the next dose determined by the responseof the previous patient (dose interval 1 mg). One group alsoreceived diamorphine 400 µg intrathecally. If a blockheight of T5 to blunt light touch had been achieved after 20min, the block was deemed effective. A difference in the ED₅₀for hyperbaric bupivacaine between the groups would indicatethat diamorphine influenced block height. Intraoperative patientdiscomfort and need for analgesic supplementation was noted. Results. The median effective dose (ED₅₀) to achieve a T5 blockto light touch for Caesarean section using hyperbaric bupivacaine0.5% was 9.95 mg [95% confidence interval (CI) 9.0–10.90]and with the addition of diamorphine it was 9.3 mg (95% CI 8.15–10.40),while the ED₉₅ was 13.55 mg (95% CI 10.10–17.0) and 13.6mg (95% CI 9.15–18.05), respectively. Five women who hadreceived intrathecal diamorphine and 13 who had not receiveddiamorphine needed intraoperative supplementation (not significant). Conclusion. The addition of intrathecal diamorphine does notappear to influence block height.     

Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery

Background. Previously, plain ropivacaine 15 mg given intrathecallyhas been shown to be feasible for ambulatory surgery of lower-extremities.Hypothetically, hyperbaric solution could improve and shortenthe block. Methods. This prospective, randomized, double-blind study included56 patients undergoing surgery of lower extremities. They receivedintrathecally either 1.5 ml of ropivacaine 10 mg ml^–1and 0.5 ml of glucose 300 mg ml^–1 (HYP) or 2 ml of ropivacaine7.5 mg ml^–1 (PL). Results. All patients in Group HYP achieved T₁₀ dermatome analgesiabut only 64% (18/28) of Group PL. T₁₀ analgesia was reachedin 5 min (median, range 5–20 min) in the HYP group vs10 min (5–45 min) in the PL group (P=0.022), and fullmotor block in 10 min (5–45 min) vs 20 min (5–60min) (P=0.003), respectively. Group HYP had a longer durationof analgesia at T₁₀; 83 min (5–145 min) vs 33 min (0–140min) (P=0.004). Duration of sensory block from injection ofthe anesthetic to complete recovery was shorter in Group HYPthan in Group PL, 210 min (120–270 min) vs 270 min (210–360min) (P<0.001), as was duration of motor block, 120 min (5–150min) vs 210 min (120–330 min) (P<0.001). Patients ofGroup HYP attained discharge criteria earlier than those ofGroup PL (P=0.009). Conclusion. In comparison with the plain solution, 15 mg ofintrathecal hyperbaric ropivacaine produced a faster onset,greater success rate of analgesia at the level of T₁₀ dermatome,and faster recovery of the block.     

Intrathecal morphine overdose during combined spinal-epidural block for Caesarean delivery

We describe a 25 mg intrathecal morphine overdose duringa combined spinal–epidural block for a Caesarean delivery.Naloxone infusion (5.24 mg over 24 h) was startedprior to the patient becoming symptomatic and almost immediatelyafter the overdose. Invasive therapeutics such as mechanicalventilation were avoided. Br J Anaesth 2002; 89: 925–7     

Dexamethasone for prophylaxis of nausea and vomiting after epidural morphine for post-Caesarean section analgesia: comparison of droperidol and saline

We have evaluated the prophylactic effect of i.v. dexamethasone8 mg in preventing nausea and vomiting during epiduralmorphine for post-Caesarean section analgesia. Droperidol 1.25 mgand saline served as the control. We studied 120 parturients(n=40 in each group) receiving epidural morphine for post-Caesareansection analgesia, in a randomized, double-blind, placebo-controlledstudy. All parturients received epidural morphine 3 mg. Bothdexamethasone and droperidol significantly decreased the totalincidence of nausea and vomiting compared with saline, withincidences of 18, 21 and 51% for the three treatments respectively(P<0.01 and P<0.05 respectively). Parturients who receiveddroperidol reported a more frequent incidence of restlessness(16%) than those who received dexamethasone (P<0.05). Br J Anaesth 2000; 85: 865–8     

Remifentanil by patient-controlled analgesia compared with intramuscular meperidine for pain relief in labour

Background. The pharmacokinetics of remifentanil suggests thatit may be suitable for analgesia during labour. Methods. In an open pilot study, 36 women requesting meperidinefor analgesia were recruited early in labour and randomizedto receive either meperidine i.m. or remifentanil given as patient-controlledanalgesia (PCA). Pain severity, sedation and anxiety were assessedwith visual analogue scales and overall effective analgesiawas assessed by the woman and midwife. Results. The pain scores were lower in the remifentanil group:median pain score at 60 min was 72 mm for meperidineand 48 mm for remifentanil (P=0.004) and median maximumpain score during the first 2 h was 82.5 mm for themeperidine group and 66.5 mm for the remifentanil group(P=0.009). Both the midwives’ and the women’s assessmentsof overall effective analgesia were higher in the remifentanilgroup [Likert scale (5 = excellent to 1 = poor):     

Comparison of phenylephrine infusion regimens for maintaining maternal blood pressure during spinal anaesthesia for Caesarean section

Background. During spinal anaesthesia for Caesarean section,the optimal phenylephrine regimen and the optimal blood pressure(BP) to which it should be titrated are undetermined. The idealregimen would balance efficacy for maintaining uteroplacentalperfusion pressure against potential for uteroplacental vasoconstriction,both of which may affect fetal acid–base status. We comparedphenylephrine infusion regimens based on three different BPthresholds. Methods. After intrathecal injection, we infused phenylephrine100 µg min^–1 for 2 min. Then, until delivery,we infused phenylephrine whenever systolic BP (SBP), measuredevery 1 min, was below a randomly assigned percentage of baseline:100% (Group 100, n=25), 90% (Group 90, n=25) or 80% (Group 80,n=24). We compared umbilical blood gases, Apgar scores and maternalhaemodynamics and symptoms. Results. Patients in Group 100 had fewer episodes [median 0(range 0–8)] of hypotension (SBP <80% baseline) comparedwith Group 80 [5 (0–18)] and Group 90 [2 (0–7)](P<0.001 in each instance). Total dose of phenylephrine wasgreater in Group 100 [median 1520 µg (interquartile range1250–2130 µg)] compared with Group 90 [1070 (890–1360)µg] and Group 80 [790 (590–950) µg]. Umbilicalarterial pH was greater in Group 100 [mean 7.32 (95% confidenceinterval 7.31–7.34)] than in Group 80 [7.30 (7.28–7.31)](P=0.034). No patient had umbilical arterial pH <7.2. InGroup 100, 1/24 (4%) patients had nausea or vomiting comparedwith 4/25 (16%) in Group 90 and 10/25 (40%) in Group 80 (P=0.006). Conclusions. For optimal management, phenylephrine should betitrated to maintain maternal BP at near-baseline values. Br J Anaesth 2004; 92: 469–74     

Analgesic efficacy of rectal acetaminophen and ibuprofen alone or in combination for paediatric day-case adenoidectomy

Background. Acetaminophen and non-steroidal anti-inflammatorydrugs have different mechanisms of action. We investigated ifcombining rectal acetaminophen with ibuprofen would providebetter postoperative analgesia compared with either drug aloneafter adenoidectomy in children. Methods. 160 children, aged 1–6 yr, undergoing day-caseadenoidectomy, were randomized to receive either acetaminophen40 mg kg^–1, ibuprofen 15 mg kg^–1, their combination,or placebo rectally immediately after anaesthetic induction.A standard anaesthetic method was used and all children receivedalfentanil 10 µg kg^–1 i.v. during induction. Meperidine5–10 mg i.v. was used for rescue analgesia for a painscore (Objective Pain Scale) over 3. Recovery times, sedationscores and the need for rescue analgesia and adverse eventsduring the first 24 h after anaesthesia were recorded. Rescueanalgesic at home was ibuprofen 10 mg kg^–1. Results. Total meperidine requirements were significantly lessin the groups receiving acetaminophen, ibuprofen, or their combinationcompared with the group receiving placebo indicating an opioid-sparingeffect of 19–28% (P<0.05). Children given acetaminophenwere more sedated than those given ibuprofen (P<0.05). Dischargecriteria were fulfilled earlier in the ibuprofen group thanin all the other groups (P<0.05). At home, less children(49%) needed rescue analgesia in the combination group comparedwith the other groups (74–77%) (P<0.02). Conclusions. We conclude that prophylactically administeredrectal acetaminophen combined with ibuprofen does not improveanalgesia after adenoidectomy in the immediate postoperativeperiod compared with either drug alone but does decrease theneed for analgesia at home. Ibuprofen results in lesser sedationand faster discharge than when acetaminophen is used. Br J Anaesth 2003; 91: 363–7