ABSTRACT
We have compared the quality of analgesia and incidence of side-effects from subarachnoid and epidural diamorphine for caesarean section, as part of a combined spinal-epidural technique. Sixty patients were studied in a randomised, double-blind, double-dummy assessment. The doses of diamorphine reflect current practice in our hospital and are close to optimal. All patients received 13.25 mg subarachnoid bupivacaine and 37.5 mg epidural bupivacaine. In addition, patients in group 1 received 0.3 mg subarachnoid diamorphine and patients in group 2 received 3 mg epidural diamorphine. All patients were premedicated with ranitidine 150 mg and metoclopramide 10 mg and after surgery received diclofenac regularly and co-dydramol as needed. The duration and quality of analgesia, assessed by verbal rating score, was the same in the two groups. The incidence and severity of pruritus were higher (P< 0.005) in group 1. Postoperative nausea and vomiting were uncommon; 83% of patients in group 1 and 77% in group 2 had none. Subarachnoid and epidural diamorphine provided similar quality analgesia with a low incidence of emetic symptoms. However, pruritus was more common and more severe after subarachnoid diamorphine.
ABSTRACT
Mothers receiving combined spinal-epidural (CSE) anaesthesia for elective caesarean section (n = 188) were audited. A single dose of epidural diamorphine (2-3 mg) was given during surgery. Unless contraindicated, diclofenac 100 mg was given per rectum at the end of surgery. Postoperative analgesia was provided as oral Co-dydramol and diclofenac. All mothers were premedicated with ranitidine 150 mg and metoclopramide 10 mg orally. Observations were recorded for 24 h postoperatively. Pain, nausea, sedation and itching were assessed on a scale of 0 (nil), 1 (mild), 2 (moderate) or 3 (severe). All mothers were reviewed during the second postoperative day. Epidural supplements during surgery and administration of naloxone, systemic opiates and anti-emetics after surgery were recorded. Postoperative analgesia was prolonged and excellent. Over 92% of pain scores were mild or less. Two mothers complained of severe pain, which was resolved with oral Co-dydramol. Postoperative morphine was not used. Itching was common but not troublesome; mild (54%), moderate (16%), severe (3%); 7% of mothers received naloxone. Nausea was uncommon: mild (19%), moderate (10%), severe (2%); 16% of mothers received anti-emetics. Itching was less than previous reports with subarachnoid diamorphine. Single dose epidural diamorphine can be used during elective caesarean section rendering systemic opiates unnecessary.
ABSTRACT
OBJECTIVE: To determine whether creatinine clearance can be determined from a single plasma creatinine measurement in patients up to 5 days after cardiac surgery. DESIGN: Observational longitudinal study. SETTING: Cardiac intensive care unit in a tertiary referral center for cardiothoracic surgery. PATIENTS: Seventy-five patients (54 men, 21 women) scheduled for elective coronary artery surgery (93 postoperative patient days). INTERVENTIONS: Creatinine clearance measurement using a 4-hour urine collection and a single arterial blood sample. MEASUREMENTS AND MAIN RESULTS: There was significant agreement (Deming analysis r = 0.63-0.84, correlation r = 0.76-0.95, p < 0.05) between the predicted creatinine clearance and the measured creatinine clearance on each of the postoperative days. This was maintained even if the patients required inotrope or vasoconstrictor therapy, were receiving parenteral nutrition, or had changing renal function (Deming analysis r = 0.67-0.7; correlation r = 0.8-0.93, p < 0.001) but does not apply to patients with preexisting renal dysfunction (Deming analysis r = 0.36; correlation r = 0.57, p = 0.002). CONCLUSIONS: In cardiac surgical patients with normal preoperative renal function, predicted creatinine clearance is as reliable as measured creatinine clearance up to the fifth postoperative day.
