Anaesthesia for caesarean section. Comparison of two general anaesthetic regimens and spinal anaesthesia

OBJECTIVES: The study was undertaken to compare different anaesthetic techniques for scheduled or urgent caesarean section with respect to maternal circulatory parameters, maternal and fetal endocrine stress response, fetal vitality parameters and further clinical parameters such as recovery and analgesic demand. METHODS: After ethical approval,patients scheduled for general anaesthesia were randomly allocated to the esketamine group ( n=21; induction with 0.5 mg/kg BW esketamine and 1.5 mg/kg BW methohexitone, ventilation until cord cutting with FiO(2) 1.0) and the sevoflurane-group ( n=21; induction with 1.5-2.0 mg/kg BW methohexitone, ventilation until uterotomia with N(2)O/O(2) [FiO(2) 0,5] and endtidal sevoflurane concentrations about 1.0 vol%).After fetal development, all patients received 2.5 microg/kg BW fentanyl and sevoflurane (about 1.0 vol% endtidal) during ventilation with N(2)O/O(2) (FiO(2) 0.33). As a further control, a group with spinal anaesthesia ( n=22; 2.6-3.0 ml isobaric bupivacaine 0.5 %) was investigated. Maternal circulatory and endocrine plasmatic stress parameters were investigated at five time points and fetal parameters once after development.alpha< or =0.05 was considered significant. RESULTS: Biometric data were comparable in all groups.Systolic arterial pressure was higher in the esketamine group ( p=0.008), whereas the heart rate was lower during spinal anaesthesia ( p<0.001).Plasma noradrenaline decreased in all collectives ( p<0.001) and mean group levels of noradrenaline ( p=0.04) and adrenaline ( p<0.001) were lower during spinal anaesthesia. In all groups, antidiuretic hormone (ADH) remained within the normal range or was slightly increased.Adrenocorticotropic hormone (ACTH) initially increased in all groups and decreased in later time course ( p<0.001).Cortisol increased in all groups ( p<0.001) but group levels were lower during spinal anaesthesia ( p<0.001). In the groups with general anaesthesia, no significant differences in recovery times were obvious, and neither recall nor dream reactions were observed.Postoperative hypoxic incidents (psaO(2) <90%) were comparable between the groups.After spinal anaesthesia, first analgesic demand was later than in the controls ( p=0.001), and the total amount of piritramide was lower ( p=0.02).Nausea and vomiting were more frequent during spinal anaesthesia ( p=0.03). All patients were content with their regimen.Apgar scores, pH-values and adrenaline, noradrenaline and cortisol in plasma were comparable in all groups of children (69 children, 5 gemini). The fetal concentration of esketamine (251 ng/ml) was lower than the corresponding maternal values (493 ng/ml). CONCLUSIONS: When compared with methohexitone, sevoflurane and N(2)O for caesarean section, initial total intravenous anaesthesia with esketamine and methohexitone mediated specific antinociception without negative maternal or fetal effects and not taking invasion kinetics or elimination between uterotomia and cord cutting into consideration. Avoidance of N(2)O allows optimal oxygenation of the fetomaternal unit.Stress protection and hemodynamic responses were well balanced, and intraoperative recall or negative dream reactions were lacking. Superior postoperative pain protection was advantageous after spinal anaesthesia, but in contrast, nausea and vomiting were more frequent in this group.     

A prospective one-year outcome study of interdisciplinary chronic pain management: compromising its efficacy by managed care policies

Although interdisciplinary pain management programs are both therapeutically effective as well as cost-effective, they are currently being underutilized because of managed care policies. We used this prospective comparison trial, with 1-yr follow-up of chronic pain patients, to demonstrate the short- and long-term efficacy of an interdisciplinary pain management program, and evaluate the impact of managed care's physical therapy "carve out" practices on these treatment outcomes. Consecutive chronic pain patients (n = 201) were evaluated, some of whom had their physical therapy "carved out" from this integrated program. Results revealed that successful completion of interdisciplinary pain management was therapeutically effective. Most importantly, physical therapy "carved out" practices had a negative impact on both the short-term and 1-yr follow-up outcome measures. Thus, interdisciplinary pain management is effective in treating the major health problem of chronic pain. However, insurance carrier policies of contracting treatment "carve outs" significantly compromise the efficacy of this evidence-based, best standard of medical care treatment. This raises important medico-legal and ethical issues. IMPLICATIONS: Interdisciplinary pain management is effective and cost-effective in treating the major health problem of chronic pain. The present study demonstrated its efficacy using a prospective, 1-yr posttreatment evaluation methodology. Moreover, physical therapy "carve out" practices by insurance carriers had a negative impact on the outcomes, raising important medico-legal and ethical issues.     

Predicting total knee replacement pain: a prospective, observational study

To describe the natural history of pain after total knee arthroplasty and to identify factors predicting excessive postoperative pain, we used a prospective, observational study assessing clinical and radiographic variables preoperatively and at 1, 3, 6, and 12 months after knee replacement. Data sources included the visual analog pain scale and other measures of patient health, psychologic state, and component reliability. Regression analyses were conducted to identify specific factors predictive of postoperative pain, controlling for inequality of variables, and confirmed using regression diagnostics. For 116 patients (149 knees; mean age, 66 years; 55.2% women), significant pain was reported by 72.3%, 44.4%, 22.6%, 18.4%, and 13.1%, respectively. No intergroup differences existed for anesthesia, weight, age, or gender. Patients with greater preoperative pain had more postoperative pain, used more home therapy, and postoperative manipulations. Preoperative depression and anxiety were associated with heightened pain at 1 year. Pain after knee replacement resolves quickly, declining to approximately (1/2) by 3 months. However, one in eight patients report moderate to severe pain 1 year after surgery despite an absence of clinical or radiographic abnormalities. Development of office-based preoperative screening tools and interventions for these patients may reduce postoperative costs and improve patient-perceived outcomes.     

Ethical considerations of applications of preimplantation genetic diagnosis in the United States

Preimplantation genetic diagnosis (PGD) was developed to offer diagnosis of genetic disorders prior to initiation of a pregnancy, whereas previously such disorders would be diagnosed at amniocentesis or chorionic villus sampling after a pregnancy had already been undertaken. Such application of this technology is not controversial. But PGD has been used to not only diagnose genetic disorders but also to select for certain other characteristics, and this use of the technique is much more controversial. A case is presented in which PGD was used not only to select against a genetic disorder, but to select for a certain HLA type which matched an affected sibling. The new child's cord blood was transplanted into his affected sister, who subsequently was found to be free of disease. The ethics of "having a child to save a child" are explored, and possible other uses of PGD that lead to eugenic outcomes are considered. The lack of regulation of this technology in the US is contrasted with existing legislation in other countries, and the need for national and international consensus regarding appropriate uses of PGD is emphasized.     

Is terminology used effectively to convey diagnostic certainty in radiology reports?

RATIONALE AND OBJECTIVES: This study was performed to assess the extent of agreement among radiologists and nonradiologists in perception of diagnostic certainty conveyed by words and phrases commonly used in radiology reports. MATERIALS AND METHODS: The study was performed in a large academic radiology department. To determine the commonly used terminology for conveying diagnostic certainty in radiology reports, 12 randomly selected radiologists from six different subspecialties were interviewed. The authors identified the 15 most commonly used words and phrases and included these in random order in a questionnaire sent to all staff radiologists (n = 45) and to 158 referring physicians. Physicians were asked to rank the 15 phrases in order of the diagnostic certainty conveyed by each, from 1 (most certain) to 15 (least certain), using each number only once. The kappa statistic was used to assess agreement in rank order among physicians. RESULTS: The questionnaire response rate was 76% (n = 34) for radiologists and 49% (n = 78) for nonradiologists. There was excellent agreement among radiologists (kappa = 0.95) and nonradiologists (kappa = 0.93) in the rank order for the phrase diagnostic of. Although there was good agreement (kappa = 0.45) among radiologists for the word unlikely, agreement among nonradiologists was poor (kappa = 0.27). There was very poor agreement among all physicians for the rank order of the other 13 phrases. CONCLUSION: Among radiologists and nonradiologists, concordance was poor regarding the diagnostic certainty associated with phrases commonly used in radiology reports. Because poor agreement could lead to suboptimal quality of care, the standardization of terminology would benefit all parties.     

Bone densitometry in children: a critical appraisal

Due to the introduction of new therapeutic regimen aimed at increasing and maintaining bone mass, bone densitometry in children has gained interest. As in all new fields of medicine we expect the interest in bone densitometry in children to increase in the coming years. Children pose a unique problem for those involved in the field of bone densitometry, because as time progresses the measured subject changes in shape and volume. It is therefore of importance that radiologists and clinicians gain insight in the available techniques. It is also important to keep in mind that all bone densitometry techniques have been exclusively designed, developed and validated for use in an adult population. In this article we give an overview of the available techniques and discuss the specific problems that can be expected when these techniques are used in children. In the discussion section general problems regarding bone densitometry in children are presented. Electronic Publication     

Benefit of cervical screening at different ages: evidence from the UK audit of screening histories

While most experts agree that cervical screening is effective, there remains controversy over the most appropriate screening interval. Annual screening is common in North America. In England, some argue for 3-yearly screening while others believe 5-yearly screening is adequate, and the frequency varies from one part of the country to another. Screening histories of 1305 women aged 20-69 years, diagnosed with frankly invasive cervical cancer and 2532 age-matched controls were obtained from UK screening programme databases. Data were analysed in terms of time since last negative, and time since last screening smear. Five-yearly screening offers considerable protection (83%) against cancer at ages 55-69 years and even annual screening offers only modest additional protection (87%). Three-yearly screening offers additional protection (84%) over 5-yearly screening (73%) for cancers at ages 40-54 years, but is almost as good as annual screening (88%). In women aged 20-39 years, even annual screening is not as effective (76%) as 3-yearly screening in older women, and 3 years after screening cancer rates return to those in unscreened women. This calls into question the policy of having a uniform screening interval from age 20 to 64 years and stresses the value of screening in middle-aged women.British Journal of Cancer (2003) 89, 88-93. doi:10.1038/sj.bjc.6600974 www.bjcancer.com