Effects of epidural labor analgesia on early neonatal sucking and breastfeeding / 中华围产医学杂志

Objective:To investigate the effects of epidural labor analgesia on neonatal sucking ability and breastfeeding.Methods:This was a prospective cohort study. Convenience sampling was used to enroll women who delivered with or without epidural analgesia (epidural analgesia and non-analgesia groups) in the Affiliated Maternity and Child Health Care Hospital of Nantong University from January 2022 to December 2022. Intra-oral negative pressure values during breastfeeding were measured by a pressure measuring instrument within 3 d after birth (0-24 h, >24-48 h, and >48-72 h), and the mean, maximum, and minimum pressure values were recorded. The Infant Breastfeeding Assessment Tool (IBAT) (Chinese version) was used to evaluate sucking posture. Breastfeeding status during hospitalization and within 1, 4, and 6 months after discharge were followed up. Two independent samples t-test, Chi-square (Fisher's exact) test, and generalized estimating equations were used for data analysis. Results:A total of 156 mother-infant pairs were analyzed in this study, with 78 pairs in the epidural analgesia group and 78 pairs in the non-analgesia group. The whole, first, and second stages of labor were longer in the analgesia group than those in the non-analgesia group [ M( P25- P75), total: 430 min (353-541 min) vs. 300 min (235-422 min), Z=－5.65; first stage: 385 min (310-490 min) vs. 260 min (205-347 min), Z=－5.81; second stage: 40 min (26-67 min) vs. 33 min (18-45 min), Z=－2.33; all P<0.05], and more women in the analgesia group accepted oxytocin and doula before delivery [94.8% (74/78) vs. 43.6% (34/78), χ2=48.15; 42.3% (33/78) vs. 19.2% (15/78), χ2=9.75; both P<0.05]. There was no significant difference in scores on the Fatigue Scale-14, Edinburgh Postnatal Depression Scale, Pittsburgh Sleep Quality Index, and Life Events Scale for Pregnant Women between the two groups. After adjusting for confounding factors by generalized estimating equations, the mean intra-oral negative pressure values in the epidural analgesia group were lower than those in the non-analgesia group at 0-24 h, >24-48 h, and >48-72 h after birth [5.14 (3.39-6.52) vs. 6.39 (4.95-9.15) kPa, 5.07 (3.94-7.38) vs. 6.20 (5.08-8.54) kPa, and 6.19 (4.64-8.36) vs. 6.81 (5.88-8.05) kPa, Wald χ2=5.59, P=0.018]; the peak value in the epidural analgesia group was also lower than that in the non-analgesia group [15.81 (9.74-21.68) vs. 16.21 (13.58- 24.88) kPa, 13.50 (9.83-16.50) vs. 17.62 (14.01-22.40) kPa, and 14.66 (10.47-18.71) vs. 18.04 (15.33- 19.85) kPa, Wald χ2=7.25, P=0.007]; there were no significant differences in the trough value between the two groups. The daily IBAT scores for the sucking position of neonates in the epidural analgesia group were all lower than those in the non-analgesia group in the first three days after delivery [10 (9-10) vs. 10 (10- 11) scores, 10 (9-11) vs. 11 (10-11) scores, and 10 (10-11) vs. 11 (11-12) scores, Wald χ2=17.05, P=0.001]. The rates of early exclusive breastfeeding within postpartum 3 d were also lower in the epidural analgesia group than those in the non-analgesia group [67.9% (53/78) vs. 75.6% (59/78), 41.0% (32/78) vs. 44.9% (35/78), and 38.5% (30/78) vs. 55.1% (43/78), Wald χ2=4.21, P=0.040]. No significant differences were found in the exclusive breastfeeding rates between the two groups at 1, 4, and 6 months after delivery. Conclusion:Epidural labor analgesia can lead to decreased early intra-oral negative pressure in neonates, affect neonatal sucking posture, and reduce the rate of exclusive breastfeeding during hospitalization, but has no significant correlation with the exclusive breastfeeding rate within six months after delivery.

Efficacy of different administration methods for labor analgesia / 中国基层医药

Objective:To investigate the clinical efficacy of different administration methods for labor analgesia.Methods:This randomized controlled study was conducted on 152 parturient women who underwent vaginal delivery at the Xinxiang Central Hospital from February to June 2023. These women were divided into a control group and an observation group, with 76 women per group. Women in the control group received 3 mL of 0.1% ropivacaine hydrochloride after routine epidural catheterization, followed by 3 mL of analgesic drugs after 3 minutes. For those without any special reactions, an analgesic pump containing 9 mL of medication was used after 3 minutes until the end of labor. In the observation group, 3 mL of 0.1% ropivacaine hydrochloride was administered as a trial dose before the epidural catheter was inserted into the epidural space. After 3 minutes, the postpartum woman lay flat and was given another 3 mL of analgesic pump medication. After 3 additional minutes, an additional 9 mL of the medication was administered. The analgesic pump was connected and turned on until the catheter was removed after delivery. The epidural catheter failure rate was assessed in each group. Before epidural puncture (T 1), within 30 minutes after the onset of anesthesia (T 2), and at the time of full dilation of the cervix (T 3), Visual Analogue Scale scores, the number of patient attempts to additionally use an analgesia pump, maternal satisfaction, the number of cases requiring cesarean section conversion, the incidence of adverse reactions (such as nausea, vomiting, and fever), and Apgar scores for newborns were recorded in each group. Results:The epidural catheter failure rate in the observation group was 1.3% (1/76), which was significantly lower than 10.5% (8/76) in the control group ( χ2 = 5.79, P < 0.05). At T 2 and T 3, the Visual Analogue Scale score in the observation group was (0.89 ± 0.08) points and (2.1 ± 0.07) points, respectively, which were significantly lower than (2.55 ± 0.07) points and (3.35 ± 0.07) points in the control group ( t = 238.54, 133.17, both P < 0.001). The number of patient attempts to additionally use an analgesia pump in the observation group was (1.00 ± 0.84) counts, which was significantly less than (4.00 ± 0.65) counts in the control group ( t = 29.47, P < 0.001). Maternal satisfaction in the observation group was 100% (76/76), which was significantly higher than 92.1% (70/76) in the control group ( χ2 = 6.25, P < 0.05). The number of cases requiring cesarean section conversion in the observation group was 0 (0/76), which was significantly lower than 52.6% (4/76) in the control group ( χ2 = 4.10, P < 0.05). Conclusion:Administering a trial dose (3 mL) of 0.1% ropivacaine hydrochloride before placing the epidural catheter during labor analgesia can greatly increase the placement success rate of the catheter and enhance pain relief effectiveness. This has a certain clinical application value.

Programmed Intermittent Epidural Bolus in Comparison with Continuous Epidural Infusion for the Effects of Enhanced Recovery after Cesarean Section / 中山大学学报(医学科学版)

ObjectiveTo compare the effects of programmed intermittent epidural bolus （PIEB） and continuous epidural infusion （CEI） on enhanced recovery after cesarean section. MethodsTotally 120 women scheduled to undergo elective cesarean section under combined spinal and epidural anesthesia， aged 18-45 years， with single fetus， full-term pregnancy （≥37 weeks）， ASA grade II or III， were recruited， with 60 cases in each group. At the end of the surgery， after a similar epidural loading dose， patients were randomLy assigned to receive either PIEB （6 mL·h-1 beginning 30 minutes after the loading dose） or CEI （6 mL·h-1， beginning immediately after the loading dose） for the maintenance of analgesia with 0.1% ropivacaine. At 2， 6， 12， 24 and 36 h postoperatively， VAS score was used to evaluate the composite pain， and Bromage Score was used to evaluate the degree of lower extremity motor block. The time to first flatus， time to first ambulation and the satisfaction scores were also recorded. ResultsThe VAS scores at 12， 24 and 36 h postoperatively and the lower extremity motor block scores at 6， 12 and 24 h postoperatively in the PIEB group were significantly lower than those in the CEI group （P < 0.01）. The epidural analgesic dosage was less in the PIEB group than that of the CEI group （P=0.002）. The time to first flatus and time to first ambulation were significantly shorter than those in the CEI group （P < 0.05）. The satisfaction scores were significantly higher in the PIEB group than in the CEI group （P < 0.05）. There was no significant difference in the first urination time after urinary catheter removal and the length of hospital stay between the two groups （P > 0.05）. ConclusionCompared with CEI， PIEB provides better postoperative analgesia， less motor block scores， lower epidural analgesic dosage， shorter the time to first flatus and defecation and time to first ambulation， and greater patient satisfaction， which is more consistent with the ERAS concept of analgesia.

Optimization strategy of labor analgesia in obese parturients: dural puncture epidural combined with programmed intermittent epidural bolus / 中华麻醉学杂志

Objective:To evaluate the optimization strategy of labor analgesia in obese parturients using dural puncture epidural (DPE) combined with programmed intermittent epidural bolus (PIEB).Methods:Eighty American Society of Anesthesiologists Physical Status classification Ⅰ or Ⅱ obese primiparae, who were at full term with a singleton fetus in vertex presentation, aged 20-40 yr, with body mass index of 30-40 kg/m 2, at 37-42 week gestation, with cervical dilation of 2-5 cm, and with visual analogue scale score ≥50 mm, were divided into 2 groups ( n=40 each) using a random number table method: DPE plus PIEB group (DPEP group) and DPE plus continuous epidural infusion group (DPEC group). All parturients received DPE labor analgesia, and parturients received PIEB (DPEP group) and continuous epidural infusion (DPEC group) to maintain analgesia during labor. In DPEP group, the patient-controlled epidural analgesia pump was set up to deliver a 5 ml bolus dose with a 20-min lockout interval and background infusion at 2 ml/12 min after an initial dose of 8 ml. In DPEC group, the patient-controlled epidural analgesia pump was set up to deliver a 5 ml bolus dose with a 20-min lockout interval and background infusion at 10 ml/h after an initial dose of 8 ml. The analgesia solution contained 0.1% ropivacaine plus 0.3 μg/ml sufentanil. The time to achieve adequate analgesia, consumption of ropivacaine per unit time, height of sensory block at the thoracic vertebral level, modified Bromage score, effective pressing times of patient-controlled analgesia, the number of rescue analgesia, Apgar score, delivery mode, occurrence of adverse reactions and maternal satisfaction with labor analgesia were recorded. Results:Compared with DPEC group, the time to achieve adequate analgesia was significantly shortened, the consumption of ropivacaine per unit time was decreased, and the number of rescue analgesia and effective pressing times of patient-controlled analgesia were decreased in DPEP group ( P<0.05). There were no significant differences in the height of sensory block at the thoracic vertebral level, modified Bromage score, Apgar score, delivery mode, incidence of adverse reactions and maternal satisfaction with labor analgesia between the two groups ( P>0.05). Conclusions:DPE combined with PIEB offers faster onset and better effect and achieves a greater local anesthetics-sparing effect when used for labor analgesia in obese parturients.

Effect of esmketamine for labor analgesia on development of postpartum depression / 中华麻醉学杂志

Objective:To evaluate the effect of esmketamine for labor analgesia on the occurrence of postpartum depression (PPD).Methods:Two hundred and forty-two cases of nulliparous parturients who selected natural labor and agreed to receive labor analgesia were selected and divided into conventional labor analgesia group (C-LA group, n=119) and esmketamine-based labor analgesia group (E-LA group, n=123). The epidural labor analgesia solution contained ropivacaine 100 mg and sufentanil 30 μg in 100 ml of normal saline in C-LA group. The epidural labor analgesia solution contained ropivacaine 100 mg, sufentanil 30 μg and esketamine 50 mg in 100 ml of normal saline in E-LA group. The Edinburgh Postnatal Depression Scale (EPDS) was used to screen parturients for depression on admission to the predelivery room and at 2 h and 1, 7 and 42 days after delivery, and EPDS scores were recorded. The patients were diagnosed as having PPD when EPDS score ≥ 9 at 7-42 days after delivery. Peripheral venous blood samples were collected on admission to the predelivery room and at 1 day after delivery to determine the concentrations of serum estrogen, progesterone, 5-hydroxytryptamine and cortisol by enzyme linked inmunosorbent assay. Results:Compared with group C-LA, the EPDS scores were significantly decreased on the 1 and 42 days after delivery( P<0.01), no significant change was found in the incidence of PPD (1.7%/0.8%, P>0.05), no significant change was found in the concentrations of serum estrogen, progesterone, 5-hydroxytryptamine and cortisol on admission to the delivery room ( P>0.05), and the concentrations of serum progesterone and cortisol were significantly increased on 1 day after delivery in group E-LA ( P<0.05). Conclusions:Combination of esketamine is helpful in reducing the risk of postpartum depression when used for epidural labor analgesia, and the mechanism is related to slowing the declines in blood levels of sex hormones and stress hormones after delivery.

Potency of epidural ropivacaine in inhibiting breakthrough pain in primiparae undergoing epidural labor analgesia / 中华麻醉学杂志

Objective:To determine the potency of epidural ropivacaine in inhibiting breakthrough pain in primiparae undergoing labor analgesia with programmed intermittent epidural bolus (PIEB).Methods:American Society of Anesthesiologists Physical Status classification Ⅰ or Ⅱ primiparae of full-termpregnancy, with a singleton fetus in vertex presentation, aged ≥18 yr, with body mass index < 30 kg/m 2, presenting with breakthrough pain during labor analgesia with PIEB, were enrolled in this study. Ropivacaine 10 ml was epidurally administered, and the concentration was determined by up-and-down sequential allocation. The initial concentration was set at 0.15% in the first patient in each group. Each time the concentration increased/decreased in the next patient depending on whether the patients showed breakthrough pain relief, and the ratio between the two successive doses was 0.9. The criterion of breakthrough pain relief was defined as numerical rating scale score < 4 points within 30 min after epidural injection of ropivacaine. The median effective concentration (EC 50) and 95% confidence interval of ropivacaine in inhibiting breakthrough pain were calculated by Dixon-Massey′s method. Results:Twenty-six patients were finally included in this study.The EC 50 (95% confidence interval)of ropivacaine in inhibiting breakthrough pain was 0.102% (0.088%-0.117%). Conclusions:The EC 50(95% confidence interval) of epidurally administered ropivacaine 10 ml is 0.102%(0.088%-0.117%) when used for inhibiting breakthrough pain during labor analgesia with PIEB in primiparae.

Analgesic effect and safety of using an epidural analgesia pump versus an intravenous analgesia pump for uterine artery embolization in the treatment of uterine fibroids / 中国基层医药

Objective:To investigate the analgesic effect and safety of using an epidural analgesia pump versus an intravenous analgesia pump for uterine artery embolization in the treatment of uterine fibroids. Methods:Fifty patients with uterine fibroids undergoing uterine artery embolization admitted to The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University from January 2019 to December 2021 were included in this study. They were divided into an observation group and a control group ( n = 25/group). Patients in the observation group used an epidural analgesia pump for pain relief, while patients in the control group used an intravenous analgesia pump for pain relief. At 1, 6, 12, and 24 hours after surgery, pain severity was compared between the two groups using the Visual Analogue Scale. Comfort level was compared between the two groups using the Bruggemann Comfort scale. Before and after surgery, respiratory rate, heart rate, blood pressure, and adverse reactions were compared between the two groups. Results:At 1 hour after surgery, the Visual Analogue Scale score in the observation group was significantly lower than that in the control group [3.00 (2.00, 5.50) vs. 7.00 (6.00, 8.00), Z = -3.84, P < 0.05]. At 6, 12, and 24 hours after surgery, there was a significant difference in the Visual Analogue Scale score between the two groups (all P > 0.05). Within 24 hours after surgery, the use of opioid analgesics in the observation group was less than that in the control group [16.00% (4/25) vs. 88.00% (22/25), χ2 = 25.96, P < 0.001]. At 1 hour after surgery, the Bruggemann Comfort Scale score in the observation group was significantly higher than that in the control group [0.00 (0.00, 0.50) vs. 0.00 (0.00, 0.00), Z = 2.08, P < 0.05]. At 6, 12, and 24 hours after surgery, there was no significant difference in the Bruggemann Comfort Scale score between the two groups (all P > 0.05). After surgery, heart rate was significantly decreased in each group compared with before surgery (both P < 0.05). There were no significant differences in respiratory rate and mean arterial pressure between the two groups before and after surgery (both P > 0.05). There were no significant differences in the incidences of postoperative nausea, vomiting, and fever between the two groups (all P > 0.05). Conclusion:The epidural analgesia pump used for uterine artery embolization in the treatment of uterine fibroids has a better analgesic effect and provides more comfort and is safer than the intravenous analgesia pump. The former is worthy of clinical promotion.

Effects of dezocine combined with sufentanil on continuous epidural analgesia after cesarean section / 中国基层医药

Objective:To investigate the effects of dezocine combined with sufentanil on continuous epidural analgesia after cesarean section.Methods:Eighty-six pregnant women who were scheduled for cesarean section in Guoyang Hospital of Traditional Chinese Medicine from February to December 2021 were included in this randomized controlled study. These women were divided into an observation group and a control group ( n = 43/group). The women in the observation group underwent epidural analgesia with dizocine, sufentanil, and ropivacaine, while those in the control group underwent epidural analgesia with dizocine and ropivacaine. The visual analogue score, Ramsay sedation score, Bruggrmann comfort scale score, and the incidence of adverse reactions were compared between the two groups. Results:At 4, 8, 12, 24 hours after surgery, the visual analogue score (VAS) in the observation group was significantly lower than that in the control group ( t = 2.34, 5.89, 15.36, 16.23, all P < 0.05). At 4, 8, 12, and 24 hours after surgery, Ramsay sedation score in the observation group was significantly higher than that in the control group ( t = -6.31, -7.64, -7.49, -7.41, all P < 0.001). At 4, 8, 12, and 24 hours after surgery, Bruggrmann comfort scale score in the observation group was significantly higher than that in the control group ( t = -7.60, -10.40, -14.53, -13.80, all P < 0.001). There was a significant difference in the number of effective analgesic pump compressions between the observation and control groups [(3.00 ± 1.41) times vs. (7.23 ± 1.31) times, t = 14.42, P < 0.001]. No adverse reactions were observed in the observation group within 24 hours after surgery. Conclusion:Dezocine combined with sufentanil for epidural analgesia can effectively improve the analgesic effects after cesarean section and is highly safe.

Effects of epidural analgesia on breast-seeking behavior and breastfeeding during breast crawling in neonates / 中国实用护理杂志

Objective:To analyze the influence of epidural labor analgesia on neonatal breast-seeking behavior and first breastfeeding.Methods:This study was an observational study. According to the cross-sectional study formula and inclusion and exclusion criteria, 150 cases of puerperas and their full-term infants who underwent vaginal delivery in the Affiliated Hospital of Southwest Medical University from March to September 2020 were included as the research objects, and the time of breast searching behavior in newborn crawling was observed and recorded. According to whether epidural analgesia was used or not, the patients were divided into analgesic group and non-analgesic group (the specific names of the two groups), and the outcome variables were analyzed.Results:There were 81 cases of successful breast crawl, 69 cases of failure, including 94 cases of epidural analgesia, 56 cases of non-epidural analgesia. Epidural analgesia had no effect on breast crawl and the time of breast searching behavior ( P>0.05). For puerperas with epidural analgesia, the total score of Breastfeeding Assessment Tool (IBFAT) and the scores of its four dimensions such as feeding time, foraging, sucking and nipple holding behavior were 9(7, 10), 3(2, 3), 2(2, 3), 2(1, 2), 2(1, 2), which lower than those non-epidural analgesia puerperas, which were 10(8, 10), 3(3, 3), 3(2, 3), 2(2, 2), 2(1, 2), the differences were statistically significant ( Z values were -6.36- -4.32, all P<0.05). Conclusions:When epidural analgesia is used clinically, medical staff need to seize the best time of drug use, pay attention to continuous monitoring of drug use duration and dosage, while exerting drug analgesia effect, it is also necessary to minimize adverse outcomes and reduce the impact of analgesics on breastfeeding.

The effects of magnesium sulfate added to epidurally administered local anesthetic on postoperative pain: a systematic review

Abstract Background This study evaluated the efficacy of epidurally administered magnesium associated with local anesthetics on postoperative pain control. Methods The study protocol was registered in PROSPERO as CRD42021231910. Literature searches were conducted on Medline, Cochrane, EMBASE, CENTRAL, and Web of Science for randomized controlled trials comparing epidural administration of magnesium added to local anesthetics for postoperative pain in elective surgical adult patients. Primary outcomes were the time to the first Postoperative (PO) Analgesic Request (TFAR), 24-hour postoperative opioid consumption, and Visual Analog Scale (VAS) scores at the first six and 24 postoperative hours. Secondary outcomes included Postoperative Nausea and Vomiting (PONV), pruritus, and shivering. Quality of evidence was assessed using GRADE criteria. Results Seventeen studies comparing epidural were included. Effect estimates are described as weighted Mean Differences (MD) and 95% Confidence Intervals (95% CI) for the main outcomes: TFAR (MD = 72.4 min; 95% CI = 10.22-134.58 min; p < 0.001; I2= 99.8%; GRADE: very low); opioid consumption (MD = -7.2 mg (95% CI = -9.30 - -5.09; p < 0.001; I2= 98%; GRADE: very low). VAS pain scores within the first six PO hours (VAS) (MD = -1.01 cm; 95% CI = -1.40-0.64 cm; p < 0.001; I2= 88%; GRADE: very low), at 24 hours (MD = -0.56 cm; 95% CI = -1.14-0.01 cm; p= 0.05; I2= 97%; GRADE: very low). Conclusions Magnesium sulfate delayed TFAR and decreased 24-hour opioid consumption and early postoperative pain intensity. However, imprecision and inconsistency pervaded meta-analyses, causing very low certainty of effect estimates.

Value of systematic education for primiparas undergoing epidural labor analgesia / 中华麻醉学杂志

Objective:To evaluate the value of systematic education for primiparas undergoing epidural labor analgesia.Methods:A total of 240 primiparas who were suitable and voluntarily requested epidural labor analgesia, aged 20-35 yr, at 37-41 + 6 weeks gestation, with a singleton fetus, in vertex presentation without fetal abnormality, were selected.According to whether the primiparas and their accompanying family members had received systematic education on epidural labor analgesia during pregnancy, the primiparas were divided into 2 groups ( n=120 each): education group and control group.When the uterine contraction was regular and the diameter of the uterine orifice reached 2 cm or more, epidural labor analgesia was carried out.Before the begining of epidural puncture, the degree of anxiety of pregnant women was evaluated using the self-rating anxiety scale.The time of communication before analgesia, time of placing body position, and satisfaction of puerperae and their family members with labor analgesia were observed and recorded. Results:Compared with control group, the self-rating anxiety scale score was significantly decreased, the time of communication before analgesia and time of placing body position were shortened, and the rate of satisfaction of puerperae and their family members with labor analgesia was increased in education group ( P<0.05). Conclusions:Systematic education is helpful in relieving the anxiety of primiparas during epidural labor analgesia, increasing the efficiency of analgesia implementation and improving the delivery experience of puerperae.

Efficacy of long-interval programmed intermittent epidural bolus during incubation period for labor analgesia / 中华麻醉学杂志

Objective:To evaluate the efficacy of long-interval programmed intermittent epidural bolus (PIEB) during the incubation period for labor analgesia.Methods:Seventy-eight nulliparous parturients who were at full term with a singleton fetus in vertex presentation, aged 22-35 yr, with body mass index of 18.0-30.0 kg/m 2, of American Society of Anesthesiologists physical statusⅠorⅡ, were divided into 2 groups ( n=39 each) using a random number table method: routine epidural bolus using a stepwise approach group (C group) and long-interval PIEB group (L group). Epidural puncture was performed at L 2, 3, and the analgesia solution was 0.1% ropivacaine and 0.5 μg/ml sufentanil in the two groups.The parturients in group C received 8 ml pulse dose per hour during the incubation period (cervical dilatation <3 cm), and 10 ml pulse dose per hour during the active phase (cervical dilatation ≥3 cm). In group L, the first pulse dose was 10 ml during the incubation period, 1.5 h later the anesthesia plane was detected, and 10 ml pulse dose was immediately given when the plane was lower than T 10, otherwise it was reevaluated 15 min later.After the interval time reached 2 h, a pulse dose 10 ml was given regardless of whether the plane was lower than T 10, and the pulse dose 10 ml was given at 1 h interval during the active phase.The numerical rating scale scores were recorded when the cervical dilatation was 3, 6 and 10 cm, and at the time of baby delivery.The duration of labor, total consumption of analgesics, and Bromage grade of lower extremities were recorded.The Apgar score <7 at 1 and 5 min after birth was recorded.The maternal adverse reactions and scores for satisfaction with analgesia were also recorded. Results:Thirty puerperae were finally enrolled in each group.The first stage of labor and total duration of labor were significantly shortened, and the total consumption of analgesics was decreased in group L ( P<0.01). There were no significant differences in the numerical rating scale scores at each time point, duration of second and third stages of labor, Bromage grade of lower extremities, incidence of adverse reactions, score for satisfaction with analgesia, and incidence of Apgar score < 7 after birth between the two groups ( P>0.05). Conclusions:When PIEB is used for labor analgesia, prolonging the infusion interval time of epidural bolus to 1.5-2.0 h during the incubation period can produce satisfactory analgesic effect and further decrease the consumption of analgesics and reduce the influence on labor stages when compared with administration using a stepwise approach.

Evaluation of efficacy of intravenous nalbuphine before epidural labor analgesia in inhibiting uterine contraction pain in primiparae / 中华麻醉学杂志

Objective:To assess the value of nalbuphine intravenously injected before epidural labor analgesia in inhibiting uterine contraction pain in primiparae.Methods:A total of 140 expectant primiparae who were suitable and willing to receive epidural labor analgesia with a singleton fetus in vertex presentation, aged 20-40 yr, of American Society of Anesthesiologists Physical Status classification Ⅰ-Ⅱ, with their cervical dilation of 2-3 cm, were divided into nalbuphine group (N group) and routine control group (C group), with 70 cases in each group.Group N received intravenous injection of nalbuphine 0.1 mg/kg (in normal saline 5 ml) at 10 min before epidural puncture, while group C received intravenous injection of the equal volume of normal saline at 10 min before epidural puncture.The epidural puncture-related items including the intensity of pain (Numeric Rating Scale [NRS] scores) and degree of sedation-agitation (Riker sedation agitation scores) during uterine contraction, duration of epidural procedure, parturients′ satisfaction with epidural puncture, successful epidural catheterization at first attempt and complications (nerve paraesthesia and inadvertent intravascular punctures) were recorded.Results:Compared with group C, the NRS scores and Riker scores for uterine contraction pain were significantly decreased during epidural procedure ( P<0.05), with NRS score <6 and Riker sedation agitation scores of 4, the duration of epidural puncture was shortened, the success rate of epidural puncture at first attempt was increased(51%/70%), and the incidence of nerve paraesthesia and inadvertent intravascular puncture was decreased(17%/6%, 14%/4%), and the parturients′ satisfaction with epidural puncture was increased in group N ( P<0.05). Conclusions:Nalbuphine 0.1 mg/kg intravenously injected before epidural labor analgesia can safely and effectively reduce uterine contraction pain without limb agitation, which is helpful in implementating epidural puncture in primiparae.

Epidural analgesia failure followed by intracranial subdural hematoma: a case report / 中华围产医学杂志

We report the diagnosis and treatment of a rare case of epidural analgesia failure followed by postpartum subdural hematoma. The patient underwent vaginal delivery under epidural analgesia at 32 +6 gestational weeks due to threatened premature labor, during which an unexpected dural rupture occurred. She gave no history of headache and there was no obvious abnormality during the pregnancy. However, on postpartum day 4, the patient complained of headache that could not be relieved when supine, but without any other neurological symptoms. A prompt cranial CT examination showed a left frontotemporal subdural hematoma. After conservative management with intravenous drip of mannitol, re-examination of cranial CT showed that the left frontotemporal subdural hematoma was mostly absorbed and the patient was discharged on postpartum day 18. The patient was healthy during follow up. Intracranial subdural hematoma after dural puncture is a rare and serious complication that requires early recognition and treatment.

Optimization efficacy of nalbuphine mixed with ropivacaine for epidural labor analgesia in primiparas: comparison with sufentanil mixed with ropivacaine / 中华麻醉学杂志

Objective:To evaluate the optimization efficacy of ropivacaine mixed with nalbuphine for epidural labor analgesia through comparison with ropivacaine mixed with sufentanil in primiparas.Methods:Four hundred and forty primiparas with a singleton fetus in vertex presentation without abnormal fetus, aged 19-36 yr, at 37-42 weeks of gestation, who were suitable and volunteered to receive epidural labor analgesia, were selected and randomly divided into observation group (NR group, n=220) and conventional group (C group, n=220).Epidural labor analgesia solution contained nalbuphine 40 mg and ropivacaine 120 mg in 150 ml of normal saline in group NR.Epidural labor analgesia solution contained sufentanil 50 μg and ropivacaine 120 mg in 150 ml of normal saline in group C. The analgesia pump was set up to deliver a 5 ml bolus dose with a 20-min lockout interval, programmed intermittent bolus 10-15 ml/h and background infusion at 2 ml/h after an initial dose of 15 ml to maintain VAS score <3.The length of labor, adverse reactions during labor analgesia, neonatal Apgar score, parameters of umbilical artery blood gas analysis and neonatal behavioral neurological assessment score were recorded. Results:Compared with group C, the incidence of urinary retention, pruritus, nausea and vomiting and fever at birth was significantly decreased in group NR ( P<0.05).The duration of the first and second stages of labor, neonatal Apgar score, pH value of umbilical artery blood, lactate concentrations, and neonatal behavioral neurological assessment score were within the normal range in both groups, and there was no significant difference between the two groups ( P>0.05). Conclusions:Compared with conventional medication, nalbuphine mixed with ropivacaine has the same efficacy when used for epidural labor analgesia in primiparas, but it has a certain optimization efficacy in terms of safety.

Anesthetic management in neurological disorders: is combined spinal-epidural a suitable option? Case report / Manejo anestésico en trastornos neurológicos: ¿es la anestesia espinal-epidural una alternativa apropiada? Reporte de caso

Abstract Tuberous sclerosis (TSC) is a rare disease with multi-systemic involvement, predominantly neurological. Little evidence exists about the anesthetic management of patients with this disorder, particularly in pregnant women. This article discusses a case of a patient with TSC admitted to our hospital for the delivery of a twin gestation. Twenty-four hours after surgery, the patient presented left-side facial-brachial hypoesthesia and headache. A brain CT revealed a right frontal cortical bleeding tumor, which was diagnosed as glioblastoma multiforme. The patient was discharged 15 days after admission and a neurosurgical approach was suggested.

Resumen La esclerosis tuberosa es una enfermedad poco frecuente asociada con compromiso multisistémico, principalmente neurológico. Es poca la evidencia sobre el manejo anestésico de los pacientes con este trastorno, en particular las mujeres embarazadas. En este artículo presentamos el caso de una paciente con esclerosis tuberosa ingresada en nuestro hospital para el parto de una gestación gemelar. Veinticuatro horas después de la cirugía, la paciente presentó hipoestesia facial y braquial izquierda y cefalea. La tomografía cerebral mostró un tumor cortical sangrante en el lóbulo frontal derecho, diagnosticado como glioblastoma multiforme. La paciente fue dada de alta 15 días después de su ingreso y, con recomendación de manejo por neurocirugía.

Superior effects of thoracic epidural block for analgesia in patients with severe acute pancreatitis / 中华麻醉学杂志

Objective:To evaluate the superior effect of thoracic epidural block (TEB) used for analgesia in patients with severe acute pancreatitis (SAP).Methods:Fifty patients of both sexes, aged 18-64 yr, with SAP, with Japanese severity score (JSS) ≥3, onset time of SAP≤12 h, were divided into conventional analgesia group (group C) and TEB group.Sufentanil was intravenously infused for analgesia in group C. TEB was performed for analgesia in group TEB.In group C, sufentanil was intravenously infused at a rate of 0.2-0.3 μg·kg -1·h -1 after admission to hospital.In group TEB, an epidural catheter was placed at T 9, 10 interspace, and 0.66% lidocaine mixed with 0.33% ropivacaine was epidurally infused at a rate of 3-5 ml/h for 120 h after admission to hospital.Visual analog scale (VAS) score and intra-abdominal pressure (IAP) were recorded at 1, 24, 48, 72 and 120 h of analgesia.HR, respiratory rate (RR), oxygenation index, computed tomography severity index (CTSI), JSS and Ranson scores were recorded at 24, 72 and 120 h of analgesia, and the de-criticalization within 72 h following analgesia was evaluated. Results:Compared with group C, VAS score and IAP were significantly deceased at each time point ( P<0.05), the rate of de-criticalization (60%/90%) was increased ( P<0.05), and Ranson score, CTSI score and JSS score were decreased at 120 h of analgesia in group TEB ( P<0.05). Conclusion:TEB can not only produce good analgesic effect, but also improve the development of the disease, which has superior effect compared with routine analgesia when used for the treatment of SAP.

Efficacy of dural puncture epidural combined with programmed intermittent epidural bolus for labor analgesia in parturients / 中华麻醉学杂志

Objective:To evaluate the efficacy of dural puncture epidural (DPE) combined with programmed intermittent epidural bolus (PIEB) for labor analgesia in parturients.Methods:A total of 200 primiparas of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, who were at full-term with a singleton fetus in vertex presentation and requested natural childbirth and intraspinal analgesia were selected and divided into 2 groups ( n=100 each) according to a computer-generated random number table: epidural block alone+ PIEB group (group E) and DPE+ PIEB group (group D). After successful epidural puncture, epidural catheter was placed in the epidural cavity, and the depth was 3-4 cm in group E. In group D, spinal needle was used for intrathecal needle puncture after successful epidural puncture, the posterior epidural catheter was placed in the epidural cavity, and the depth was 3-4 cm.The epidural pulse pump (0.08% ropivacaine plus sufentanil 0.4 μg /ml) was connected and was set up to deliver a 5-ml bolus dose with initial dose 10 ml, a 20-min lockout interval and background infusion at a rate of 10 ml/h.The onset time of analgesia, development of the sensory block reaching S 2 within 30 min after administration, development of motor block, effective pressing times and consumption, requirement of ropivacaine for rescue analgesia, ropivacaine consumption and delivery mode were recorded.The development of hypotension, pruritus, nausea, vomiting, headache after puncture and fetal bradycardia were recorded.The Apgar scores at 1 and 5 min after delivery were recorded and the parturients were followed up on 1 day after delivery for the scores for satisfaction with analgesia. Results:Compared with group E, the onset time of analgesia was significantly shortened, the ratio of sensory block reaching S 2 was increased, analgesia pump pressing times and ropivacaine consumption were decreased ( P<0.05), and no significant change was found in the incidence of motor block, the requirement for rescue analgesic, the scores for parturients′ satisfaction with analgesia, delivery mode, Apgar scores of the neonates and the incidence of adverse reactions in group D ( P>0.05). Conclusion:DPE combined with PIEB for labor analgesia can shorten the onset time of analgesia and provide reliable efficacy and higher safety.

Effect of epidural labor analgesia administration methods on occurrence of postpartum urinary retention in nulliparous parturients: a comparison between programmed intermittent epidural bolus and continuous epidural infusion / 中华麻醉学杂志

Objective:To evaluate the effect of epidural labor analgesia administration methods on occurrence of postpartum urinary retention in nulliparous parturients through a comparison between programmed intermittent epidural bolus (PIEB) and continuous epidural infusion.Methods:Two hundred nulliparous parturients who were at full term with a singleton fetus in vertex presentation, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, aged 22-35 yr, with body mass index of 22.4-42.6 kg/m 2, were divided into 2 groups ( n=100 each) using a random number table method: continuous epidural infusion group (group CEI) and group PIEB.Patient-controlled epidural analgesia (PCEA) was performed in active phase of labor (cervical dilatation≥1 cm) during the first stage of labor.The PCEA solution contained the mixture (10 ml) of 0.1% ropivacaine with 0.5 μg/ml sufentanil.The PCEA pump was set up to deliver a 5-ml bolus dose with a 30-min lockout interval.The analgesia solution contained the mixture (100 ml) of 0.08% ropivacaine and sufentanil 0.5 μg/ml.In group CEI, the drugs were given at 8 ml/h immediately after the initial dose.PIEB regimens were programmed as 8 ml over 80 s once an h after the initial bolus, and the administration was stopped after delivery of fetus.The labor time, consumption of analgesia solution and the incidence of postpartum urinary retention were recorded. Results:Compared with group CEI, the duration of the second stage of labor was significantly shortened, and consumption of analgesia solution and the incidence of postpartum urinary retention were decreased in group PIEB ( P<0.05). Conclusion:Compared with the continuous epidural infusion, the application of PIEB in labor analgesia can reduce the incidence of postpartum urinary retention in nulliparous parturients.

Esofagectomía minimamente invasiva / Minimally invasive esophagectomy

INTRODUCTION: Minimally invasive esophagectomy aims to reduce complications compared to open esophagectomy. In this report of the first patient undergoing this procedure at Hospital Pasteur, we highlight the importance of multidisciplinary management, and the main anesthesiological objectives. OBJECTIVE: To present the case report highlighting the anesthetic management, together with the bibliographic review carried out in order to update the anesthetic action protocols, with the main objective of reducing the appearance of perioperative complications. MATERIAL AND METHOD: Bibliographic search in PubMed bibliographic databases. Initially, 67 articles were obtained, selecting 20 considered relevant by the authors. CLINICAL CASE: It was a 46-year-old patient coordinated for esophagectomy for squamous neoplasm. Rapid sequence induction, selective endobronchial intubation and anesthetic maintenance with Isoflurane and epidural analgesia were performed. The hydroelectric replacement was restricti- ve. The surgical technique was performed in 3 stages: thoracic time by thoracoscopy; a second laparoscopic abdominal stage and a third stage for left cervicotomy. Extubation was carried out in the operating room with transfer to the ICU where she remained for 6 days to manage analgesia and due to the presence of a mild infectious complication, with good subsequent evolution. CONCLUSION: The use of perioperative multidisciplinary management protocols has fundamental importance as a strategy aimed at reducing morbidity and mortality. Advances in surgical technique added to anesthetic management constitute strategies that aim to reduce perioperative complications.

INTRODUCCIÓN: La esofagectomía minimamente invasiva tiene como objetivo disminuir las complicaciones en comparación con la esofagectomía abierta. En este reporte del primer paciente sometido a este procedimiento en el Hospital Pasteur destacamos la importancia del manejo multidisciplinario, y los principales objetivos anestesiológicos. OBJETIVO: Presentar el reporte de caso destacando el manejo anestésico, junto con la revisión bibliográfica realizada en vistas a la actualización de protocolos de actuación anestésica, con objetivo principal de disminuir la aparición de complicaciones perioperatorias. MATERIAL Y MÉTODO: Búsqueda bibliográfica en las bases bibliográficas PubMed. Inicialmente se obtuvieron 67 artículos, seleccionando 20 considerados relevantes por los autores. CASO CLÍNICO: Se trató de una paciente de 46 años coordinada para esofagectomía por neoplasma epidermoide. Se realizó inducción en secuencia rápida, intubación endobronquial selectiva y mantenimiento anestésico con Isofluorano y analgesia peridural. La reposición hidroelectrolítica fue restrictiva. La técnica quirúrgica se realizó en 3 tiempos: tiempo torácico por toracoscopía; un segundo tiempo abdominal laparoscópico y un tercer tiempo para cervicotomía izquierda. La extubación se realizó en sala de operaciones con traslado a CTI donde permaneció por 6 días para manejo de la analgesia y por presencia de complicación infecciosa leve, con buena evolución posterior. CONCLUSIÓN: Resulta de fundamental importancia el uso de protocolos de manejo multidisciplinario perioperatorio como estrategia destinada a disminuir la morbimortalidad. Los avances en cuanto a la técnica quirúrgica sumado al manejo anestésico constituyen estrategias que apuntan a disminuir las complicaciones perioperatorias.