Effectiveness of spinal anesthesia after epidural labor analgesia versus spinal anesthesia only for intrapartum cesarean section

BACKGROUND: Spinal anesthesia (SA) after epidural labor analgesia (ELA) can have advantages over augmentation of ELA due to its rapid onset and high-quality analgesia. However, unexpected side effects and diverse failure rates have been reported in women that received SA after ELA. We prospectively compared the effectiveness and side effects of SA after ELA versus SA only for intrapartum cesarean section. METHODS: The ELA/SA group received continuous epidural infusion at a rate of 10 ml/h for labor pain. In both groups, spinal anesthesia was induced with 10 mg of 0.5% hyperbaric bupivacaine and 15 microg of fentanyl using a pencil point needle. The rate of conversion to general anesthesia, the need for intraoperative analgesic supplements, and the incidence of high spinal block and hypotension were investigated. RESULTS: The rate of conversion to general anesthesia was higher in the ELA/SA group compared with the SA group (15.2 vs. 2.7%). Eighty percent of the conversion cases in the ELA/SA group were converted due to lack of sensory block. The need for intraoperative analgesic supplements and the rates of high spinal block and hypotension were comparable in the two groups. CONCLUSIONS: SA after ELA is associated with a high rate of conversion to general anesthesia during intrapartum cesarean section.

The effects of epidural analgesia on maternal fever and neonatal outcomes

BACKGROUND: In low-risk women at term, epidemiologic studies have shown that fever in nulliparous parturients during labor is related to epidural use. Moreover, effects of fever associated with epidural analgesia on adverse neonatal outcomes have been debated. The purpose of this study is to evaluate the influence of epidural analgesia on intrapartum fever, neonatal outcomes in deliveries including nulliparity and multiparity. METHODS: We retrospectively investigated normal full-term spontaneous deliveries during 2012. Of 3,858 mother-infant pairs, 3,179 (82%) parturients received and 679 (18%) parturients did not receive epidural analgesia during labor. We regarded intrapartum fever greater than 37.5degrees C, and the parturients with fever were treated with intravenous propacetamol. We divided the study population according to labor epidural analgesia use and, fever and compared the incidence of fever and neonatal outcomes. RESULTS: Incidence of fever was higher in the epidural group compared with the no epidural group (21 vs. 5%). The number of babies with a 1 min Apgar < 7 was lower in the no epidural with no fever group, and neonatal seizure was more frequent in the epidural with fever group compared with the no epidural without fever group, no epidural with fever group, and the epidural without fever group. CONCLUSIONS: Incidence of fever was increased in the epidural analgesia group. Adverse neonatal outcomes were more frequent in the epidural with fever group. No conclusion whether the epidural analgesia cause neonatal adverse outcomes can be drawn due to confounding factors.

The effects on Apgar scores and neonatal outcomes of switching from a combination of phenylephrine and ephedrine to phenylephrine alone as a prophylactic vasopressor during spinal anesthesia for cesarean section / 대한마취과학회지

BACKGROUND: Ephedrine, unlike phenylephrine, has a dose-related propensity to depress fetal pH during spinal anesthesia during cesarean section. A low arterial umbilical cord pH has a strong association with neonatal mortality and morbidity. The purpose of this retrospective study was to investigate influences of vasopressor change on Apgar scores and adverse neonatal outcomes in cesarean section. METHODS: In obstetric anesthesia, we changed the prophylactic vasopressor from a combination of phenylephrine and ephedrine to phenylephrine alone in 2000. We evaluated the impact of vasopressor change on Apgar scores (1 and 5 min), incidence of Apgar score < 7 (1 and 5 min), neonatal seizure, continuous positive airway pressure (CPAP), intermittent positive pressure ventilation (IPPV), intraventricular hemorrhage (IVH), periventricular leucomalacia (PVL), and hypoxic ischemic encephalopathy (HIE) in low-risk elective cesarean sections during a period when the combination of phenylephrine and ephedrine was used (2008-2009, two years) and the period of phenylephrine use alone (2011-2012, two years). RESULTS: There were no differences in Apgar scores (1 and 5 min), the incidence of 5 min Apgar score < 7, neonatal seizure, CPAP, IPPV, IVH, PVL, and HIE between the two time periods. However, the incidence of 1 min Apgar < 7 was decreased during the period of phenylephrine use compared with the period of phenylephrine and ephedrine use (P = 0.002). CONCLUSIONS: Conversion from a combination of phenylephrine and ephedrine to phenylephrine alone as a prophylactic anti-hypotensive drug during spinal anesthesia for cesarean section in low-risk pregnancy may be associated with a significant decrease in the incidence of 1 min Apgar < 7.

Cardiac arrests in placenta accreta patient during emergency cesarean section: A case report

We report the case of a patient who suffered two events of sudden cardiac arrests separately. Sudden onset of dyspnea and cardiac arrests occurred during cesarean section in a 35-year-old woman who delivered premature baby. Instant chest compression and epinephrine 1 mg was administered. She was diagnosed to have a placenta previa totalis with bleeding preoperatively and placenta accreta was noted intraoperatively. Cesarean hysterectomy was performed due to excessive hemorrhage associated with uterine atony. Another cardiac arrests occurred during hysterectomy. After instant successful resuscitation, she recovered her heart rhythm and transferred to tertiary hospital safely. She was discharged about two months later without any major physical or neurocognitive deficits.

A case of pneumocephalus during labor epidural analgesia: A case report

Pneumocephalus can be developed after a dural puncture, which occurs in association with epidural procedures. A 37-year-old, gestational age 40 weeks, pregnant woman was admitted for vaginal delivery. She asked for epidural analgesia when she suffers with labor pain. Epidural anesthesia was done at the L3-L4 interspace with the loss of resistance technique, using air. During the identification of the epidural space, an accidental dural puncture was diagnosed by observing a free flow of CSF, through the needle. The patient developed headache 2 hours later. She was treated with hydration, oxygen, analgesics and the autologus blood patch procedure was done, at the L4-L5 interspace. Despite these measures, the patient's symptoms worsened with nausea and vomiting. A brain CT scan showed the presence of pneumocephalus. After 100% oxygen therapy and metoclopramide injection, she was discharged on postpartum 2 days, without any complications.

The Effect of Perioperative Intravenous Lidocaine Infusion on the Recovery of the Bowel Function after a Laparoscopic Hysterectomy / 대한마취과학회지

BACKGROUND: The postoperative bowel function can affect the number of hospital days and morbidity. This study examined the effect of intravenous lidocaine on the postoperative bowel function. METHODS: Forty patients scheduled to undergo a laparoscopic hysterectomy were randomly allocated to receive intravenous lidocaine or an equal volume of saline. The lidocaine group received a continuous lidocaine infusion of 2 mg/kg/hr intraoperatively and for one hour after surgery. The saline group received an equal volume of saline. The time to the first flatus, defecation and hospital discharge were recorded. The incidence of postoperative nausea and vomiting (PONV) were assessed. The consumption of intravenous patient controlled analgesia (IV-PCA) over a twenty-four hour period and the dose of the rescue drug were measured. The visual analogue scale of pain was assessed at the recovery room and 24 hour after surgery. The side effects of intravenous lidocaine were recorded. RESULTS: The patients' demographics were similar in both groups. The median time to the first flatus was 30 hours in the lidocaine group and 42 hours in the saline group (P < 0.05). The median time to defecation was 65.5 hours in the lidocaine group and 96 hours in the saline group (P < 0.05). The number of hospital days was similar. Intravenous lidocaine significantly decreased the level of IV-PCA consumption (P < 0.05). In the lidocaine group, the incidence of PONV was significantly lower (P < 0.05), and no side effects were observed. CONCLUSIONS: Intravenous lidocaine facilitates the recovery of the bowel function after a laparoscopic hysterectomy by reducing the flatus time and defecation time. In addition, the level of IV-PCA consumption after surgery and the incidence of PONV were also reduced by intravenous lidocaine.