Retrospective Analysis of Anesthesia for Cesarean Section of the Patients with Hypertensive Disorders in Pregnancy for 15 Years / 이화의대지

OBJECTIVES: To compare the clnical data of general and regional anesthesia for cesarean section in patients with systemic hypertension. METHODS: We conducted a retrospective survey with the medical records of the patients with hypertensive disorders in pregnancy, who under went cesarean section from January 1998 to December 2012. We collected data including patients' demographics, anesthesia and maternal and neonatal outcome. According to anesthetic method, the subjects were divided into general anesthesia and regional anesthesia group and the clinical outcome were compared. We reclassified the patients according to the use of magnesium sul fate (MgSO4) and compared the clinical outcomes. RESULTS: Of the 1,050 hypertensive parturients, 848 (80.8%) patients went through cesarean section. Three hundred and sixty three patients (42.8%) underwent epidural anesthesia, general and spinal anesthesia were used in 268 (31.6%), and 217 (25.6%) patients, respectively. There was no significant difference in maternal and neonatal outcome according to anesthetic method. In the patients administered MgSO4, 1 minute Apgar score was lower and maternal gestational age and birth weight were less than the patients not receiving MgSO4. CONCLUSION: Anesthetic methods did not have effect on outcome of cesarean section of the patients with hypertensive disorder of pregnancy.

Intracerebral hemorrhage after inadvertent dural puncture and cesarean section under general anesthesia: A case report

Epidural analgesia is frequently used for control of labor pain. Seizure of parturient could be misdiagnosed as eclampsia. A parturient presented a generalized tonic clonic seizure during first stage of labor in two and a half hour after dural puncture and epidural blood patch. She had received an emergency cesarean section under general anesthesia and had another seizure during transfer to the intensive care unit. A brain computed tomography showed intracerebral hemorrhage and pneumocephalus. After conservative treatment, she could discharge without any sequelae in 13 days. The anesthesiologists should be aware of the possibility of intracerebral hemorrhage when they confront a seizure of parturient although there is no evidence of relation between dural puncture and intracerebral hemorrhage.

Effect of Injection Speed of Local Anesthetic on Hypotension during Spinal Anesthesia for Cesarean Section / 이화의대지

OBJECTIVES: Maternal hypotension is a common problem during cesarean section under spinal anesthesia. We evaluated the influence of injection speed of local anesthetic to subarachnoid space on maternal hypotension and level of sensory block. METHODS: Bupivacaine (0.5%) 9 mg with fentanyl 10 microg was injected to subarachnoid space either quickly (during 20 seconds, 0.1 mL/sec, n=20) or slowly (during 100 seconds, 0.02 mL/sec, n=20) in parturients scheduled for elective cesarean section. The onset and level of sensory block was checked and heart rate and blood pressure was checked by 2.5 minutes during 20 minutes. Hypotension (systolic blood pressure <100 mmHg or <70% of baseline) was treated with ephedrine. RESULTS: Hypotension occurred 70% of parturients with spinal anesthesia. Slow injection didn't influence on the onset and level of sensory block and didn't reduce the incidence of hypotension. But onset of hypotension was delayed. CONCLUSION: Slow injection (during 100 seconds, 0.02 mL/sec) of local anesthetic delayed onset of hypotension and required less amount of ephedrine. Slow injection of local anesthetic was one of the effective methods for the cardiovascular stability during cesarean section under spinal anesthesia.

Effect of epidural analgesia on cesarean section in nulliparous women

BACKGROUND: The effect of epidural analgesia for labor on obstetric outcome is controversial. The purpose of this study is evaluating the influence of epidural analgesia on cesarean section in nulliparous women. METHODS: We retrospectively investigated 979 nulliparous women ASA graded I - II. EPI (n = 230) was received epidural analgesia with 0.2% ropivacaine and 75microgram fentanyl. N-EPI (n = 749) was received no epidural analgesia but nalbuphine 10 mg intramuscularly. We compared the rate and causes of cesarean section, instrumental delivery rate and fetal outcomes between EPI and N-EPI. RESULTS: Cesarean section rate was not different between the EPI (18%) and N-EPI (23%). Causes of cesarean section were progress failure (83% in EPI and 80% in N-EPI) and fetal distress (17% in EPI and 20% in N-EPI) and there were no differences between two groups. Instrumental delivery rate was higher in EPI (8%) than N-EPI (5%). Fetal outcome was not different between two groups. CONCLUSIONS: Epidural analgesia did not increase cesarean section rate and did not influence on causes of cesarean section. But epidural analgesia increased the vacuum delivery rate.

Pulmonary edema following intramyometrial injection and paracervical infiltration of vasopressin during laparoscopic myomectomy and LAVH (Laparoscopic abdominal vaginal hysterectomy): A report of 2 cases

Vasopressin is often used locally to reduce blood loss in gynecologic surgery. The use of local infiltration of low concentration vasopressin (0.05-0.3 units/ml) has been considered to be safe. However, serious side effects such as bradycardia, hypertension, arrhythmia, pulmonary edema, coronary vasospasm, myocardial infarction and even cardiac arrest were reported during low-dose vasopressin. In 2 healthy women with myoma and multiple myoma combined with adenomyosis, we experienced pulmonary edema after intramyometrial injection and paracervical infiltration of vasopressin. After diuretics and oxygen therapy, the patients were recovered without any complications.

The onset and duration of 0.2% ropivacaine with a varying dose of fentanyl in epidural labor analgesia

BACKGROUND: The purpose of this study was to identify the effect of fentanyl dose on the onset and duration of 0.2% ropivacaine. METHODS: Sixty-one nulliparous women with singleton vertex pregnancy who requested epidural labor analgesia were enrolled. Patients were administered randomly 0, 50, 100microgram of fentanyl with 10 ml of 0.2% ropivacaine (Group F0, F50 and F100, respectively). VAS pain scores were recorded 0, 5, 10, 15 min after epidural injection, after which they were recorded every 15 min. The onset and duration of analgesia were measured. Side effects such as, pruritus, motor blockade, and hypotension were recorded.Satisfaction scores, type of delivery, and neonatal outcomes were recorded. RESULTS: The onset of analgesia was at 8.5 +/- 3.4 min in Group F100, compared with 13.7 +/- 7.2 min in Group F0 and 13.6 +/- 5.3 min in Group F50 (P = 0.009). The duration of analgesia was 122.6 +/- 20 min in Group F100, compared with 72.3 +/- 21.2 min in Group F0 and 97.8 +/- 22.4 min in Group F50 (P = 0.000). There were significant differences in VAS pain scores and satisfaction scores among the three groups. There were no differences in the incidences of maternal side effects and operative delivery or neonatal outcomes. CONCLUSION: Fentanyl 100microgram was the most appropriate dose when combined with 0.2% ropivacaine due to the rapid onset and long duration of epidural labor analgesia.

Clinical evaluation of anesthesia for cesarean section of the patients with hypertensive disorders in pregnancy: retrospective study for 10 years

BACKGROUND: There are many difficulties in anesthetic management for cesarean section of the patients with hypertension.The anesthetic management of hypertensive disorders in pregnancy has been controversial. METHODS: We reviewed the medical records of the patients with hypertensive disorders in pregnancy from Jan., 1998 to Dec., 2007, and made clinical analysis of the anesthesia for cesarean section. RESULTS: Of the total 775 parturients with hypertensive disorders, 638 (82.3%) was delivered by cesarean section.Indications for cesarean section were, in order of frequency, hypertensive disorders in pregnancy (36.9%), multiple pregnancy (13.8%), previous cesarean section (11.6%), etc.Of the total cesarean section, 468 (73.4%) were emergency cases.The majority of preoperative systolic blood pressures were 141-160 mmHg (36.2%) and 161-180 mmHg (35.2%). The majority of preoperative diastolic blood pressures were 91-100 mmHg (28.6%) and 101-110 mmHg (25.0%). 350 (54.9%) had epidural anesthesia, 195 (30.5%) had general anesthesia, and 93 (14.6%) had spinal anesthesia.Estimated blood loss was significantly lower after regional anesthesia than after general anesthesia.In patients received magnesium sulfate (MgSO4), (40.0% of total) 83.5% had regional anesthesia and 16.5% had general anesthesia.In the cases with MgSO4 1 min Apgar score was lower and neonatal birth weight was smaller than in cases without MgSO4. CONCLUSIONS: Anesthesiologist must have much attention on the prevention, treatment and anesthetic management for cesarean section of patients with hypertensive disorders in pregnancy.

The comparison of intravenous anesthesia with fentanyl versus alfentanill during oocyte retrieval for in vitro fertilization / 대한마취과학회지

BACKGROUND: This study was carried out to compare the effect of intravenous anesthesia with fentanyl or alfentanil on the hemodynamic profile, sedation, recovery and side effect in the patients undergoing oocyte retrieval. METHODS: The patients were designed to receive alfentanil (group A, n = 70) or fentanyl (group F, n = 70) intravenous anesthesia. The patients were given midazolam 0.6 mg/kg and alfentanil 15 microgram/kg in group A or fentanyl 1.5 microgram/kg in group F. Propofol 0.7 mg/kg was given if patient was awaken during procedure. Hemodynamic changes, propofol used dosage and initial propofol injecting time, Ramsay Sedation Scales, cough reflex on opioid injection, recovery time, duration of apnea and postoperative nausea, vomiting at the recovery room were recorded. RESULTS: Group A had rapid onset, deep sedation, less amount of propofol used, more frequent apnea than group F. There were no significant differences in postoperative nausea, vomiting and recovery time between the two groups. CONCLUSIONS: The intravenous anesthesia with fentanyl or alfentanil are suitable for oocyte retreival but apnea happened more frequent in alfentanil group, so the use of alfentanil needs to monitor ventilation and hemodynamic changes carefully.

The comparison of intravenous anesthesia with fentanyl versus alfentanill during oocyte retrieval for in vitro fertilization / 대한마취과학회지

BACKGROUND: This study was carried out to compare the effect of intravenous anesthesia with fentanyl or alfentanil on the hemodynamic profile, sedation, recovery and side effect in the patients undergoing oocyte retrieval. METHODS: The patients were designed to receive alfentanil (group A, n = 70) or fentanyl (group F, n = 70) intravenous anesthesia. The patients were given midazolam 0.6 mg/kg and alfentanil 15 microgram/kg in group A or fentanyl 1.5 microgram/kg in group F. Propofol 0.7 mg/kg was given if patient was awaken during procedure. Hemodynamic changes, propofol used dosage and initial propofol injecting time, Ramsay Sedation Scales, cough reflex on opioid injection, recovery time, duration of apnea and postoperative nausea, vomiting at the recovery room were recorded. RESULTS: Group A had rapid onset, deep sedation, less amount of propofol used, more frequent apnea than group F. There were no significant differences in postoperative nausea, vomiting and recovery time between the two groups. CONCLUSIONS: The intravenous anesthesia with fentanyl or alfentanil are suitable for oocyte retreival but apnea happened more frequent in alfentanil group, so the use of alfentanil needs to monitor ventilation and hemodynamic changes carefully.

Anaphylaxis after Induction of General Anesthesia for Cesarian Section : A case report

A 35 year old multipara woman was admitted for emergency repeat cesarian section. She had first cesarian section under general anesthesia 3 years ago, and appendectomy under spinal anesthesia 2 years ago. But no uneventful problem developed in two cases of anesthesia. After induction of general anesthesia with propofol and succinylcholine, the patient showed irritability and severe cough, and immediate anaphylactic reaction developed with cardiovascular collapse, bronchospasm, and erythematous skin eruption. We resuscitated the patient with epinephrine and methylprednisolone but cesarian section was performed without delay. Four minutes after the induction of anesthesia female baby was delivered and the patient was recovered without any complication.

Cardiac Arrest during Epidural Anesthesia: A Case Report / 대한마취과학회지

We report a case of sudden cardiac arrest requiring external thoracic cardiac massage in a 40-year old healthy man receiving epidural anesthesia for elective vasovasostomy. The anesthetic procedure was performed in an operating room. Bradycardia and hypotension occurred 10 minutes after local anesthetic injection. Atropine 0.5 mg and ephedrine 10 mg were administered intravenously, but cardiac arrest followed with unconsciousness and apnea. Atropine 0.5 mg and epinephrine 1 mg were administered intravenously, and external cardiac massage was performed synchronously. The heart rate promptly increased, and the consciousness and spontaneous respiration of the patient were restored. Vital signs became stable in the recovery room and the patient recovered with no sequelae. We conclude that sudden bradycardia and cardiac arrest can unexpectedly develop during epidural anesthesia, and that close monitoring of the patient and adequate management are essential.

Two Cases of Subcutaneous Emphysema and Pneumomediastinum Identified During the Laparoscopic Tubal Anastomosis / 대한산부인과학회잡지

Over the last few decades, laparoscopy has evolved from a useful diagnostic tool to a complex surgical method. With its increasing popularity, the complications associated with laparoscopy are also increasing in number and variety. Subcutaneous emphysema, a complication related to the pneumoperitoneum, may result in hypercarbia, pneumomediastinum, and pneumothorax. It can result in even respiratory failure in serious cases. However, it may be easily detected with the signs of increased maximum positive end-tidal CO2 (PETCO2) and crepitus. Fortunately, most of them are recovered by proper conservative management. We report two cases of subcutaneous emphysema and pneumomediastinum identified during laparoscopic tubal anastomosis.

Evaluation of Predictive Factors for the Difficult Intubation in Pregnant Women / 대한마취과학회지

BACKGROUND: Difficult tracheal intubation during anesthetic induction can be a lifethreatening situation, especially in pregnant women. This is the leading cause of anesthetic related maternal mortality. The ability to predict such cases preoperatively would be of great value. We conducted a prospective study to investigate the incidence of difficult intubation and the usefulness of various predictive factors for difficult intubation in pregnant women. Metoods: Predictive studies on three hundred nine pregnant women who underwent general anesthesia and tracheal intubation for an elective caesarean section were conducted using airway measurements such as a modified Mallampati classification (m-MP), interincisor gap (IG), thyromental distance (TMD), and sternomental distance (SMD). Then direct laryngoscopic gradings (LG) and difficult intubation (DI) were determined. All patients were evaluated on the basis of these studies, and the sensitivity, specificity, positive and negative predictive values (PPV, NPV) of each study were calculated. RESULTS: DI was observed in 5 patients (1.62%) and failed intubtion was observed in 1 patient (0.32%). The sensitivity and specificity of the m-MP were 80% and 82% respectively, and those of the IG were 80% and 77% respectively. A combination of the m-MP and IG resulted in high sensitivity and specificity (100% and 76% respectively), but low PPV (5%). CONCLUSIONS: This study concluded that m-MP and IG were the most sensitive and specific tests when used alone or in combination.

Effect of Obstetric Epidural Anesthesia on the Progress of Labor / 대한산부인과학회잡지

No abstract available.

Effect of Continuous Epidural Analgesia on the Progress of Labor / 대한마취과학회지

BACKGROUND: The effect of epidural analgesia on the progress of labor is controversial. The objective of this study is to determine the effect of analgesia on the outcomes of labor, especially the cesarean delivery rate in the epidural and non-epidural (intramuscular nalbuphine) groups, prospectively. METHODS: All the nulliparous women were divided into two groups, group 1 (epidural group, n = 35) and group 2 (non-epidural group, intramuscular nalbuphine, n = 43) randomly. Epidural analgesia was maintained with a continuous epidural injection of 0.0625% bupivacaine with 0.2 microgram/ml fentanyl in group 1 and nalbuphine 10 mg was intramuscularly injected in group 2 when the cervix was dilated to at least 3-5 cm. The duration of the first and second stages of labor, cesarean delivery rate, Apgar score and body weight of infant were recorded and the pain score of parturient was recorded by 0-100 mm visual analogue scale. RESULTS: The duration of first and second stage were prolonged in the group 1 (epidural group). But there were no significant differences in the duration of first and second stage, Apgar score and body weight of infant between the two groups. Cesarean delivery rate was 16% (n = 7/35) in group 1 and 17% (n = 6/43) in group 2, so there was no significant difference between the two groups. Pain score was significantly lower in group 1 than in group 2. CONCLUSIONS: Epidural analgesia was not associated with increased cesarean delivery rate and provided safe and effective intrapartum pain control. Maternal-fetal factors and obstetric management, not epidural analgesia, are the most important determinants of the cesarean delivery rate.

The Effect of Different Route of Preanesthetic Ranitidine on Gastric Acidity in Patients Undergoing Elective Cesarean Section / 대한마취과학회지

BACKGROUND: Aspiration of gastric contents is an ever -present risk in the use of general anesthesia, particularly in emergency and obstetric situations, and morbidity and mortality associated with this complication increases with the volume and acidity of the aspirate. Since direct inhibition of acid secretion may be a preferable method, we studied the effectiveness of ranitidine in increasing gastric pH. METHODS: Sixty patients scheduled for elective cesarean section under general anesthesia before midday were randomly divided into three groups. The control group (n=20) did not received preanesthetic ranitidine. Group I (n=20) received a slow intravenous injection of 50 mg ranitidine, one hour before surgery. Group II (n=20) received 150 mg ranitidine orally, both the night before surgery and the morning of surgery. RESULTS: Compared with the control group, the mean gastric pH increased significantly in group I and II (P<0.05). There was no significant difference of gastric pH between group I and II. CONCLUSIONS: The results of this study indicate that ranitidine is a useful agent in increasing the gastric pH in women undergoing elective cesarean section. Ranitidine administered intravenously and orally were equally effective means in increasing the gastric pH.

Are the Requirements of Propofol Decreased in Early Pregnancy during Anesthetic Induction? / 대한마취과학회지

BACKGROUND: Minimum alveolar concentration (MAC) is decreased during pregnancy, but there are no data regarding the requirements for intravenous agents. Recently only one study showed that the requirement for thiopental in pregnant women of 7-13 weeks' gestation was less than the requirement obtained in nonpregnant women. Thus we wanted to determine whether pregnant patients needed less propofol for hypnosis and anesthesia than nonpregnant patients. METHODS: One hundred nonpregnant women having gynecologic surgery and 100 pregnant women of 5-13 weeks' gestation undergoing elective abortions were recruited. They were randomly allocated 10 groups according to the doses of propofol and each group had 10 patients. During a period of 30 seconds, one of the doses of propofol 1.0, 1.25, 1.5, 1.75, 2.0, 2.25, 2.5, 2.75, 3.0 or 3.25 mg/kg was administered. Two minutes later, patients were asked to open their eyes as a test for hypnosis. Patients who did not open their eyes were given a 10 seconds, 50-Hz, 80-mA transcutaneous tetanic electrical stimulus to the ulnar nerve as a test for anesthesia. Estimates of ED50 and ED95 for hypnosis and anesthesia were obtained by logistic regression. RESULTS: In the pregnant women, the median effective doses (ED50) (95% confidence interval) for hypnosis and anesthesia were 1.25 (1.13-1.35) mg/kg and 2.71 (2.49-3.04) mg/kg, the ED95 (95% CI) were 1.51 (1.16-1.87) mg/kg and 3.04 (2.80-3.58) mg/kg respectively. Whereas in the nonpregnant women, the ED50 for hypnosis and anesthesia were 1.27 (1.39-1.90) mg/kg and 4.12 (3.50-6.01) mg/kg, the ED95 were 1.53 (1.41-1.93) mg/kg and 4.35 (3.66-7.26) mg/kg respectively. CONCLUSIONS: In early pregnant women, the doses of propofol for hypnosis and anesthesia were 1.6% and 34.2% less compared with those in nonpregnant women.

Preload with Ringer's Lactate Solution for Elective Cesarean Section : Effect on the Epidural Anesthesia Induced Hypotension / 대한마취과학회지

BACKGROUND: Hypotension associated with epidural anesthesia for cesarean section is common and serious, despite the use of uterine displacement and volume preload. This study evaluated the role of crystalloid volume preload for prevention of hypotension during epidural anesthesia. METHODS: Forty parturients undergoing elective cesarean section were allocated randomly to receive either no preload (Group II, n=20) or preload with Ringer's lactate solution 1000 ml over 10-15 minutes (Group I, n=20) before epidural anesthesia. Hypotension was defined as a decrease of systolic blood pressure to less than 90 mmHg and to less than 80% of baseline value. Systolic blood pressure and heart rate were measured 2 minutes interval during first 20 minutes after epidural injection. Apgar score, umbilical venous, arterial and maternal arterial blood gas analysis were done. RESULTS: Significant hypotension occured in seven of the twenty parturients in no preload group (Group II) and seven of twenty parturients in Ringer's lactate preload group (Group I). There were no statistical differences in systolic blood pressure, heart rate, amount of used ephedrine, Apgar score, umbilical venous, arterial and maternal arterial blood gas analysis. CONCLUSIONS: Ringer's lactate preload (1000 ml) before epidural anesthesia in the supine tilted parturients did not decrease the incidence or severity of hypotension.

Cardiovascular Collapse during Gynecologic Endoscopy: Report of 2 cases / 대한마취과학회지

Hysteroscopy is an established gynecologic procedure that has been used for the past 20 years as a diagnostic technique. It is also used therapeutically. Hysteroscopy is commonly performed with CO2insufflation and its complications are rare. The sudden decrease of end-tidal partial pressure of carbon dioxide, associated with mill-wheel murmur, loss of cardiac output and sinus tachycardia on the ECG are highly suggestive of massive gas embolism during laparoscopy and hysteroscopy. We report 2 cases of cardiac arrest and severe bradycardia. The second patient's expired CO2 concentration fell rapidly to 7 mmHg and blood pressure and heart rate dropped suddenly after resection of the uterine septum and adhesiolysis. We performed cardiac resuscitation with cardiotonic drugs, cardiac compression, defibrillator and resulted in good recovery. At the time of discharge 10 days and 2 days later, the patients had recovered almost completely.

The Effect of Metoclopramide and Ondansetron on Postoperative Nausea and Vomiting Following Propofol Injection as Induction Agent in Laparoscopic Surgery / 대한마취과학회지

BACKGROUND: Postoperative nausea and vomiting (PONV) are common problems in patients undergoing outpatient laparoscopy and hysteroscopy. Associated complications range in severity from mild discomfort to hospital admission for dehydration or pulmonary aspiration. This study was designed to assess the efficacy of 2 antiemetics (metoclopramide and ondansetron) with propofol as the induction agent for prophylaxis of postoperative emesis in women undergoing general anesthesia for gynecologic endoscopic surgery. METHODS: One hundred and twenty six healthy women undergoing laparoscopic and hysteroscopic surgery with general anesthesia were randomized to receive intravenous bolus of saline 2 ml, metoclopramide 10 mg, ondansetron 4 mg prior to induction of anesthesia. Anesthesia was induced with propofol 2~2.5 mg/kg, vecuronium 0.1 mg/kg and maintained with O2, N2O, enflurane, fentanyl 1~2 microgram/kg. The incidence of nausea and vomiting was assessed at recovery room and all patients were contacted 24 hours after discharge. RESULTS: The incidence of PONV showed 11.9% in control group, 11.9% in metoclopramide group and 9.5% in ondansetron group in recovery room. The incidence of PONV showed 14.3% in control group, 14.3% in metoclopramide group and 7.1% in ondansetron group in 24 hours postoperatively. There were no significant differences among the groups. CONCLUSIONS: When propofol was administered by intravenous induction agent, no antiemetic in this study was more efficacious than propofol alone in reducing PONV for women undergoing outpatient laparoscopic and hysteroscopic surgery.