The Effect of Epidural Phenylephrine on Hypotension Induced by Epidural Anesthesia for Cesarean Delivery / 대한마취과학회지

BACKGROUND: Hypotension can occur after high level of epidural anesthesia. Like ephedrine, epidural phenylephrine is known to reduce the incidence of hypotension induced by the epidural administration of lidocaine. The purpose of this study was to determine whether combining epidural phenylephrine can reduce the incidence of hypotension in epidural anesthesia. METHODS: Ninety-two patients undergoing a cesarean section were divided into three groups. Patients assigned to three groups received 20-25 ml of lidocaine containing fentanyl 50 microgram with one of three doses of phenylephrine; 0 microgram (Group 1), 100 microgram (Group 2), or 200 microgram (Group 3), injected via the lumber epidural catheter. The mean blood pressure and heart rate were recorded every 10 min for 1 h after injection and were compared among the groups. Pinprick testing was performed to determine the highest level of sensory block and the time to two-segment regression. Also, the incidence of hypotension and ephedrine required were investigated. RESULTS: The incidence of hypotension was 37%, 28%, and 40% in Group 1-3, respectively. The time to two-segment regression was 94.7 +/- 21.6 in group 1, 100.8 +/- 20.1 min in Group 2, compared to 118.2 +/- 26.3 min in Group 3. CONCLSIONS: We found that epidural phenylephrine significantly prolonged the duration of epidural anesthesia, but it was ineffective for preventing hypotension induced by lidocaine epidural anesthesia.

Prevention of Nausea and Vomiting during Spinal or Epidural Anesthesia for Cesarean Section - The Efficacy of Metoclopramide and Droperidol - / 대한마취과학회지

BACKGROUND: Regional anesthesia for cesarean section is associated with a high incidence of nausea and/or vomiting (N&V) during the operation. Metoclopramide and droperidol have been known to be effective in the prevention of N&V. However, they have been reported to induce some adverse effects such as sedation. We evaluated the efficacy of metoclopramide and droperidol in the prevention of N&V in spinal and epidural anesthesia for cesarean section. METHODS: A prospective randomized double-blind study was performed on 180 parturients scheduled for elective cesarean section. They were allocated into spinal or epidural (n = 90, each) anesthesia groups and each group into either a placebo, metoclopramide, or droperidol drug group (n = 30, each). After delivery, 2 ml saline, 10 mg metoclopramide, or 0.625 mg droperidol was given to the parturients, respectively. Incidences of N&V and sedation during the operation were checked, and the other adverse effects of the anesthesias such as hypotension and visceral pain were compared among the groups. The height of sensory blockade was also checked. RESULTS: Epidural anesthesia was more related with N&V than spinal (P = 0.030). Among the groups there was a significant difference in the incidence of N&V (P = 0.002). There were fewer parturients with N&V in the droperidol group than in the placebo group during epidural anesthesia (P = 0.021). During both spinal and epidural anesthesia more parturients in the droperidol group had sedation than placebo or metoclopramide groups (P = 0.0001) and more in the metoclopramide group than in the pacebo group (P = 0.01). No differences were found in incidences of hypotension and in the height of sensory block among the groups. There were more parturients with visceral pain during epidural anesthesia (P = 0.031). CONCLUSIONS: Epidural anesthesia provoked N&V more frequently than spinal anesthesia for cesarean section. Only droperidol was effective in the prevention of N&V during epidural anesthesia, but had a more sedative effect than metoclopramide during either spinal or epidural anesthesia.

Effect of Labor Epidural Analgesia on Rates of Cesarean Section and Vacuum Delivery / 대한마취과학회지

BACKGROUND: This study was done to compare vacuum delivery and cesarean section rates in a large population before and after on-demand labor epidural analgesia became available. METHODS: We retrospectively investigated the overall sets of delivery modes in patients who gave birth during a 12-month period before the introduction of on-demand labor epidural analgesia, and those giving birth after labor epidural analgesia became available. Additionally, we compared the rates of cesarean section or vacuum delivery in patients delivering before and after the availability of on-demand labor epidural. RESULTS: Included were 3905 patients who delivered before, and 4318 patients who delivered after epidural analgesia became available. Labor epidural rates were 0.3% vs 14.7% for the before and after groups. The rates of cesarean delivery for dystocia in primary cesarean operation did not change (10% vs 10.5%), and vacuum delivery rates in the total vaginal delivery patients were not changed (15.1% vs 14.7%) for the before and after group. CONCLUSIONS: Increased epidural analgesia did not change the overall cesarean delivery rates for dystocia and vacuum - assisted delivery rates.

A Case of Anesthetic Management for a Pregnant Woman with Unruptured Cerebral Aneurysm Undergoing Simultaneous Cesarean Section and Aneurysm Clipping: A case report / 대한마취과학회지

Intracranial aneurysm in pregnancy imposes special consideration for both mother and fetus. During newborn delivery, the risk of aneurysmal rupture should be avoided by careful management. We experienced a case of cesarean section and the clipping of aneurysm in 37 years old pregnant woman at the gestational age of 35 weeks. She had suffered from headache since 30 weeks of gestational age and the ptosis of left eye since 33 weeks of gestational age. Ten millimeter-sized aneurysm of posterior communicating artery was found on the cerebral angiogram. After radial artery cannulation, we anesthetized the woman with nitroprusside infusion, thiopental, succinylchoine and nitrous oxide-oxygen-isoflurane gas mixture. Soon after intubation, systolic blood pressure increased from 140 to 150 mmHg during the infusion of sodium nitroprusside. The delivery of a newborn was done 8 min after induction and clipping of aneurysm was done successfully after the end of cesarean section.

A Case Report of Epidural Anesthesia for Cesarean Section in a Patient with Takayasu's Arteritis / 대한마취과학회지

Takayasu's arteritis is a chronic, idiopathic occlusive inflammation of the aorta and its major branches, affecting females in over 85% of the cases. The major clinical finding is loss of palpable pulses in the upper limbs and neck. Several authors have cautioned against the use of regional anesthesia in Takayasu's arteritis, because of the dangers of hypotension and subsequent vasopressor use. However, regional anesthesia, with an awake patient, is the easiest way to monitor cerebral function and is the preferred technique in the parturient. We report on a case of Takayasu's arteritis associating renovascular hypertension during pregnancy with successful cesarean delivery under epidural anesthesia.

Two Cases of Epidural Anesthesia for Patients with Moyamoya Disease Presenting for Elective Cesarean Section: 2 cases report / 대한마취과학회지

Moyamoya disease is a rare progressive occlusive disease of the internal carotid arteries, along with the presence of an abnormal capillary network of vessels at the base of the brain. There are few reports regarding moyamoya disease during pregnancy. Since hyperventilation-induced cerebral ischemia and hypertension are provoked by active labor, elective cesarean section has been recommended to avoid neurologic complications for pregnant women with moyamoya disease. The optimal anesthetic management for cesarean section in these patients has not been discussed. We describe two cases of epidural anesthesia for elective cesarean section for patients with known moyamoya disease, which were delivered successfully.

Cardiac Arrest in Preeclamptic Patient with Unrecognized Heart Failure during Induction of General Anesthesia for Cesarean Section / 대한마취과학회지

Better medical management, together with a number of newer surgical techniques, has enable more girls with congenital heart disease to reach childbearing age. Congenital heart lesions now constitute at least half of all cases of heart disease encountered during pregnancy. Pregnancy is characterized by marked increase in stroke volume and cardic output during the antepartum period. The hemodynamic demands of pregnancy dangerously stress the impaired cardiovascular reserve. We experienced that a case of cardiac arrest in a preeclamptic patient with unrecognized heart failure during induction of the general anesthesia for cesarean section. We found out later that she had an operation because of patent ductus arteriosus at the age of 15 and then already had mitral valve regurgitation and LVH findings in the echocardiogram. We suggested that heart failure was enhanced by the hyperdynamic cardiovascular changes of normal pregnancy and further aggrevated by preeclampsia and anemia.

Anesthesia for a Patient with Moyamoya Disease presenting for Emergency Cesarean Section: A case report / 대한마취과학회지

Moyamoya disease is a rare, progressive, occlusive cerebrovascular disorder characterized by bilateral stenosis of the intracranial portion of the internal carotid artery. Symptoms including transient ischemic attacks, seizures, intracranial hemorrhage and cerebral infarction, are variable. There are few case reports of moyamoya disease in pregnancy. Since hyperventilation-induced cerebral ischemia and hypertension are provoked by active labor, cesarean section has been recommended to avoid neurologic complications for pregnant women with moyamoya disease. The optimal anesthetic management for cesarean section in these patients has not been discussed. We report a case of moyamoya disease in a patient presenting for cesarean section at 40 weeks' gestation. Epidural anesthesia was administered using 0.5% bupivacaine and fentanyl. Intraoperative hemodynamic state was stable. The patient has no significant postoperative complications.

Comparative Maternal and Neonatal Effects of Propofol, Propofol-Ketamine and Ketamine as Induction Agents in Cesarean Section / 대한마취과학회지

BACKGROUND: Propofol and ketamine had been used for anesthesia induction and for total intravenous anesthesia. The nature of any hypnotic interactions occurring between propofol and ketamine are unknown. A comparison of maternal and neonatal effects among propofol-ketamine combination, ketamine and propofol were studied when used for anesthesia induction in Cesarean section. METHODS: Forty five patients in ASA class I or II scheduled for Cesarean section randomly assigned to either propofol 2 mg/kg (n=15), ketamine 1 mg/kg (n=15) or propofol 1 mg/kg - ketamine 0.5 mg/kg combination group (n=15) as an induction agent. Maternal systolic and diastolic blood pressure, heart rate, Apgar score and umbilical blood gas analysis were measured. RESULTS: Before intubation, systolic and diastolic pressure were decreased in propofol group but increased in ketamine and propofol-ketamine combination group. Heart rate were increased in all three groups. But there were no significant differences among three groups (p<0.05). After intubation, there were significant increase in systolic, diastolic pressure and heart rate in three groups but no significant differences among three groups (p<0.05). And there was no significant neonatal depression as assessed by Apgar scores and blood gas analyses. CONCLUSIONS: Propofol-ketamine combination was found to be similar to propofol or ketamine only in the effects on the mother and neonate. But propofol-ketamine gained more stable hemodynamic change than propofol or ketamine before intubation. Therefore propofol-ketamine appears to be a suitable alternatives to propofol or ketamine as an induction agent for anesthesia in Cesarean section.

The Combined Spinal Epidural Anesthesia Using Meperidine and Lidocaine for Cesarean Section / 대한마취과학회지

BACKGROUND: To reduce the disadvantages with both epidural and spinal block, a combined spinal epidural(CSE) technique was introduced by Brownridge in 1981. The effect of the combined spinal-epidural block was compared with the spinal block for elective cesarean section. METHODS: Fifty healthy parturients were randomly divided into a spinal(n=20) group and a CSE(n=30) group. In the spinal group, 0.5 ml of 5% meperidine(25 mg) mixed with 40~50 mg of 5% hyperbaric lidocaine was injected into the subarachnoid space . In the CSE group, 0.5 ml of 5% meperidine also was injected into the subarachnoid space through a long 26-gauge Quincke needle, which was introduced through an 18-gauge Tuohy needle. An epidural catheter was then inserted and 1.5% lidocaine 7~9 ml was given. RESULTS: 1) The mean time interval from the end of drug injection to T4 sensory block was 3.6?1.0 min in the CSE block and 3.6?1.2 min in the spinal block. The mean level of peak sensory block was T3.3?0.6 in the CSE block and T3.5?0.5 in the spinal block. The time interval between the end of drug injection and Bromage scale 0 of the CSE block(62.1?27.9 min) was significantly (p<0.0001) shorter than the spinal block(102.1?24.0 min). Hypotension ocurred in 14 patients(47%) of the CSE block and 10 patients(50%) of the spinal block. The surgical analgesia was exellent or good in both groups. CONCLUSIONS: The CSE block using meperidine and hyperbaric lidocaine for cesarean section resulted in rapid onset, good surgical analgesia and rapid motor recovery. And incidence of hypotension of the both groups was not significantly different.

Acute Pulmonary Edema Occurred During the Cesarean Section in a Patient with Ritodrine Pretreatment: A case report / 대한마취과학회지

The mechanism of development of pulmonary edema associated with -sympathomimetic agent is still not fully understood. 2-sympathomimetic drugs such as ritodrine, terbutaline, and fenoterol are widely used for the treatment of premature uterine contraction. We describe a case of pulmonary edema that occurred suddenly during Cesarean section in a previously healthy parturient, associated with ritodrine pretreatment for 5 days in an attempt to arrest preterm labor. Pulmonary edema was completely treated with mechanical ventilation and diuretic therapy.

Clinical Anaylsis of Anesthetic Dosage and Use of Ephedrine in Epidural Anesthesia for Cesarean Section / 대한마취과학회지

BACKGROUND: Hypotension occurs frequently after epidural anesthesia. Intravenous fluid or vasopressors are among treatment methods to many suggested causes. This study was undertaken retrospectively to determine if the age, weight and height of parturients are related to the local anesthetic dosage in epidural anesthesia for the cesarean section, and if the dosage of local anesthetic influence the change of blood pressure and the requirement of fluid or epherine. METHODS: Sixty-nine parturients were studied by reviewing patients' anesthetic records. During lumbar epidural anesthesia to T4 sensory level, all patients were monitored with mean arterial blood pressure, and prevented from hypotension by administration of Ringer's lactated solution. But if hypotension has been sustained in spite of rapid fluid loading, intermittent ephedrine was injected. We studied the correlation of local anesthetic dosage, decrement of mean blood pressure and total required intravenous fluid volume, and difference of these variables between cases using ephedrine and not using. RESULTS: The volume of local anesthetic to achieve a T4 sensory level was 21.20 3.81ml, which did not correlate with age, weight and height, and did not influence the decrease of mean blood pressure and the volume of administered fluid. But the patients (n=30) who needed ephedrine were adminstered significantly larger dose of the local anesthetic and showed more decrease in the mean blood pressure than those (n=39) who did not. CONCLUSIONS: The dose requirement of local anesthetic during epidural anesthesia for the cesarean section is not determined by the age, weight and height of parturients. But when larger dose of local anesthetic is administered, the patients seem to be more hypotensive and need ephedrine as well as intravenous fluid administration.

The Effect of Crystalduringloid Administration on Blood Pressure and Heart Rate Change during Epidural Anesthesia in Cesarean Section / 대한마취과학회지

BACKGROUND: Recently, epidural anesthesia for elective and emergency cesarean section is increasing in popularity and graudally replacing general anesthesia. However, the complications from the epidural anesthesia such as hypotension, dyspnea, nausea and vomiting have often been reported. This study was designed to estimate the efficacy of crystalloid administration on blood pressure and heart rate change during epidural anesthesia in cesarean section. METHODS: Forty ASAI and II patients scheduled for cesarean section under epidural anesthesia were randomly allocated to receive either only maintained fluid administration(group I) or 15 ml/kg crystalloid solution over 15 minutes(group II). Epidural anesthesia was performed in a lateral decubitus position. According to the patient's height, 20~23 ml of 2% lidocaine was injected through epidural catheter at the L3~4 interspace. RESULTS: Cardiovascular responses and complications after induction of epidural anesthesia were compared and results were as follows. The incidence of hypotension was 14/20 (70%) in the groupI and 4/20(25%) in the group II(p<0.05). Systolic blood pressure after induction of epidural anesthesia in the group I significantly decreased from 6 min to 12 min as compared to the group II. The mean heart rate after induction of epidural anesthesia in the both group was no significant difference to baseline heart rate. CONCLUSIONS: Considering above results, we conclude that a prophylactic crystalloid solution infusion is effective for minimizing and managing hypotension associated with epidural anesthesia in cesarean section.

Epidural Anesthesia for Cesarean Section in a Parturient with Eisenmenger's Syndrome -A case report- / 대한마취과학회지

Eisenmenger' syndrome is defined as pulmonary hypertention with right-to-left or bidirectional shunt with peripheral cynosis. All patients with Eisenmenger' syndrome are at markedly increased risk and poor prognosis. We experienced a case of 31-year-old, pregnancy 36 weeks with Eisenmenger's syndrome secondary to PDA and Down syndrome. We carefully performed epidural anesthesia with fractionated doses of 2 % lidocaine and fentanyl. The sensory block reached to T6 level. Monitoring included ECG, invasive blood pressure, finger pulse oximetry and central venous pressure. Blood pressure was maintained with intravenous phenylephrine. Blood loss was promptly replaced with crystalloid solution and FFP. Postoperative pain was managed successfully with continuous epidural infusion of 0.2 % bupivacaine and fentanyl. The mother and baby were discharged home 1 week later without complicaton.