Similar incidence of hypotension with combined spinal-epidural or epidural alone for knee arthroplasty

BACKGROUND: We hypothesized that the incidence of hypotension during total knee replacement (TKR) surgery is lower in patients given combined spinal-epidural (CSE) anesthesia vs those receiving epidural anesthesia alone. METHODS: In a prospective study, 80 American Society of Anesthesiologists I-II patients (aged 40-80 yr), undergoing elective TKR surgery were randomly assigned to either CSE anesthesia (CSE, n = 40) or epidural anesthesia alone (Epidural, n = 40). Hemodynamic measurements included oscillometric mean arterial blood pressure (MAP), heart rate (HR), and cardiac index (CI) as determined by thoracic bioimpedance; systemic vascular resistance (SVR) was calculated. Our primary endpoint (outcome) was the number of hypotension episodes (defined as MAP < 70 mmHg). RESULTS: Using univariate analysis, we found no differences between the groups in regards to MAP, HR, CI, or SVR during the perioperative period. The incidence of hypotension was similar in both groups (two patients in each group), as was the incidence of bradycardia (12 patients in CSE, 7 in Epidural; P = 0.2). There were no differences between groups in other hemodynamic measurements including CI and calculated SVR. Analgesia supplementation with fentanyl was more frequently required in the Epidural group (20 vs 6 patients - P = 0.03). CONCLUSION: Combined spinal-epidural anesthesia and epidural anesthesia alone during TKR surgery are associated with the same incidence of hypotension with statistically and clinically similar hemodynamic responses.     

Symptomatic hyponatraemia due to inappropriate antidiuretic hormone secretion following minor surgery

A rare case of the syndrome of inappropriate antidiuretic hormone secretion occurring after minor surgery is presented. A ten-year-old, previously healthy boy underwent general anaesthesia for detorsion and right orchiopexy. Throughout the operations, which lasted for one hour, he received 120 ml Ringer's lactate solution. The immediate postoperative period was uneventful. Twenty-two hours postoperatively he was found unconscious with generalized tonic-clonic seizures. Simultaneously obtained serum sodium concentration (121 mEq.L-1) serum osmolarity (265 mEq.L-1), urine sodium concentration (87 mEq.L-1) and urine osmolarity (525 mEq.L-1) suggested inappropriate antidiuretic hormone secretion which was confirmed by an elevated serum arginine-vasopressin (AVP) level of 14.5 pcg.ml-1 (normal 1-5 pcg.ml-1) measured by radioimmune assay. He was treated with a single iv dose of 30 mg furosemide and fluid restriction, which produced a gradual increase of his serum sodium concentration to normal within two days. He was well during the remainder of his hospitalization.     

Influence of Epidural Anaesthesia on the Course of Labour in Patients with Antepartum Fetal Death

The course of labour in 22 patients with antepartum fetal death who received epidural anaesthesia was evaluated as compared to 22 controls matched for parity and gestational age, who received narcotic pain relief. Both groups had similar preinduction cervical dilatation and the induction was performed by amniotomy and oxytocin infusion. The mean first stage of labour was 5.4 hours in the epidural group, and 8.7 hours in the controls (p = 0.0192). The mean cervical dilatation rate was 3.3 cm/hour and 1.0 cm/hour respectively (p = 0.0142). The second stage was similar in both groups. We conclude, that parturients receiving epidural anaesthesia may benefit both emotionally and physically from excellent pain relief and a shorter delivery process when going through the distressing experience of delivering a dead fetus.     

Patient-controlled epidural analgesia for labor pain: effect on labor, delivery and neonatal outcome of 0.125% bupivacaine vs 0.2% ropivacaine

The objective was to evaluate the influence of patient-controlled epidural analgesia (PCEA) using low doses of bupivacaine vs. ropivacaine, on labor pain, motor blockade, progression of labor, delivery and neonatal outcome. This randomized double blind study included 565 parturients. All received a 5-mL/h infusion and PCEA (5-mL boluses with a 20-min lockout, maximum volume 20 mL/h) of either 0.125% bupivacaine (n = 313: 165 nulliparous, 148 parous) or 0.2% ropivacaine (n = 252: 113 nulliparous, 139 parous). Pain score, lower limb motor block, sensory levels, local analgesic doses required, hemodynamic parameters, side effects and complications were assessed. Obstetric variables included cervical dilation at epidural insertion, incidence of ruptured membranes and their duration, use of oxytocin, fetal heart rate changes, duration of labor, mode and outcome of delivery, and use of invasive and non-invasive fetal monitoring. Neonatal characteristics included birth weight, Apgar scores, umbilical artery pH, serum bilirubin, hypoglycemia, need for assisted ventilation, sepsis or sepsis study, feeding difficulties and respiratory distress syndrome. Ropivacaine 0.2% was equianalgesic with 0.125% bupivacaine, but produced less motor block (P < 0.0001). There were no significant differences, however, in duration of labor, delivery type or neonatal outcome.     

Efficiency of the operating room suite

BACKGROUND: The need to control high costs of running operating rooms while providing for timely patient care led us to assess the time wasted in the operating room (OR). METHODS: OR use by two general surgery and two orthopedic departments in a metropolitan public hospital were analyzed, and the time elapsed when a scheduled OR remained unused or the patient was still awaiting surgery was measured. RESULTS: OR "time-waste" defined as the time in which the scheduled OR was not busy with the scheduled patient amounted to 79 hours over the 30-day study period (15% of total time). It was wasted owing to inappropriately prepared patients (12%), unavailability of surgeons (7%), insufficient nursing staff, anesthesiologists, or OR assignment to emergency surgery (59%), congestion of the postanesthesia care unit (10%), and delay in transport to the OR (2%) Another issue delineated was the frequent occurrence of surgical cases running longer than their scheduled time (termed "spill-over"), outrunning the staffing expectations after 3:00 PM and delaying admission of add-on and emergency procedures, adding 33% to the time wasted. A quality-assurance committee review resulted in implementation of new guidelines, and within 3 months several underlying causes were rectified, and time-waste and spill over time was reduced by 35%. Surgical time predictions were also improved. Shortage of nurses and anesthesiologists, and OR emergency reassignment remained the major causes of OR waste time. CONCLUSIONS: Continuous surveillance on OR suite-patients' prompt care, repeated evaluation, and wise staff deployment-could maximize OR efficiency.