Intrapartum sonography for occiput posterior detection in early low dose combined spinal epidural analgesia by sufentanil and ropivacaine.

AIM: To evaluate the incidence of occiput posterior position in labour with and without combined spinal epidural analgesia (CSE) by low dose of sufentanyl and ropivacaine. MATERIAL AND METHODS: This study focused on 132 women subdivided in two groups, patients in spontaneous and in labour analgesia, administered by a low dose CSE by sufentanyl and ropivacaine; all women were evaluated by digital examinations and ultrasound till delivery. All data were collected and analyzed by an independent reviewer. RESULTS: In the second stage, 79 were persistent occiput posterior position (POPP) fetuses and 36 were translated from anterior to posterior position (TAPP) fetuses. Specifically, in spontaneous labour on 25 women in anterior position, there were 17 TAPP and in CSE analgesia on 28 women in anterior, there were 19 in TAPP, without significant differences. The number of asynclitisms was higher in the POPP group (84%) respect to the TAPP group (75%), so as the rate of caesarean section (67% versus 52.7%). CONCLUSIONS: The labour with low dose of ropivacaine and sufentanyl does not increase the occiput posterior position during fetal descent, leading to a POPP. Finally, since in the occiput anterior presentation labour analgesia significantly lengthens time to delivery, in the occiput posterior position this is significantly increased, with a prolonged second stage of labour and reduced time of descent of fetal head in obstetric pelvis.

Adding sufentanil to levobupivacaine or ropivacaine intrathecal anaesthesia affects the minimum local anaesthetic dose required.

BACKGROUND: We carried out this prospective, randomized, double-blind study in order to evaluate whether the intrathecal addition of sufentanil 3.3 mcg affects both the minimum local anaesthetic dose (MLAD) of spinal levobupivacaine and ropivacaine for a caesarean section and enhances the spinal block characteristics. METHODS: One hundred and eighty women were randomly allocated into four groups: levobupivacaine (Group L), levobupivacaine plus sufentanil (Group L+S), ropivacaine (Group R) and ropivacaine plus sufentanil (Group R+S). Each received 3 ml of the study solution intrathecally as part of a combined spinal/epidural technique. The initial dose was 12 mg for Groups L and L+S, and 15 mg for Groups R and R+S. The test solution was required to achieve a visual analogue pain score (VAPS) of 30 mm or less to be considered effective at skin incision, uterine incision, birth, peritoneal closure and at the conclusion of surgery. Effective or ineffective responses determined a 0.5 mg decrease or increase of the same drug, respectively, for the next patient in the same group, using an up-down sequential allocation. RESULTS: Using the Dixon and Massey formula, the MLAD was 10.65 mg [confidence interval (CI) 95%: 10.14-11.56] in Group L, 4.73 mg (CI 95%: 4.39-5.07) in Group L+S, 14.12 mg (CI 95%: 13.50-14.60) in Group R and 6.44 mg (CI 95%: 5.86-7.02) in Group R+S. CONCLUSIONS: The addition of sufentanil reduced the MLAD of both the local anaesthetics. It did not affect their potency ratio significantly and resulted in enhanced spinal anaesthesia.

Long-term epidural analgesia treatment in pre-eclamptic women: a preliminary trial.

Pre-eclampsia (PE) is a clinical pregnancy-related condition, characterised by an elevated blood pressure and proteinuria. The author treated selected cases of PE with long-term epidural analgesia (LTEA), that reduced labour pain and operated directly on the PE aetiopathogenesis, not on the symptoms. A total of 15 women with PE were hospitalised at 35-37 weeks of pregnancy, checked for blood pressure, liver and renal function, platelet count and had an epidural catheter inserted for a continuous administration of an analgesic mixture of Naropin, Sufentanil and Clonidine. The average weeks at delivery were 37 weeks and 1 day; 10 women had a spontaneous delivery and five a caesarean section: the mean birth weight was 2,906 g and the Apgar scores at 1 min and 5 min exceeded 7 in all cases. All the parameters improved after hospital admission and at discharge. All the patients were discharged in good condition and no patients needed supplementary antihypertensive treatment. The LTEA utilisation for 1 week is well tolerated and improves uteroplacental perfusion, but further studies and a larger number of patients are required to evaluate this pharmacological procedure and determine its place in the management of PE.

Spontaneous splenic vein aneurysm rupture in the puerperium.

A case of intra- and retroperitoneal haemorrhage after a splenic vein aneurysm rupture is described. A 27-year-old woman complained of chest pain on her first postpartum day. Symptoms were initially suggestive of pulmonary embolism, but within 3 h she developed severe acute abdominal pain, abdominal distension and haemodynamic instability. Ultrasound demonstrated a non-echogenic mass in the abdomen suggestive of a fluid collection and a computed tomography scan confirmed the presence of a lesion at the pancreatic tail. Urgent laparotomy revealed splenic vein rupture near the pancreatic tail. Partial pancreatectomy and splenectomy were performed. The patient subsequently made an uneventful recovery. Histological examination revealed a splenic vein aneurysm and chronic inflammatory changes in the pancreatic tissue. Rupture of a splenic vein aneurysm is a rare event and the diagnosis may present difficulty because its presentation is similar to several other more common conditions. However, rupture of a splenic vein aneurysm should be suspected in any pregnant woman with unexplained abdominal pain or with clear signs of haemorrhage, as delay in diagnosis can have devastating consequences.

Efficacy and comparison of 0.5% levobupivacaine with 0.75% ropivacaine for peribulbar anaesthesia in cataract surgery.

BACKGROUND AND OBJECTIVE: The low cardiovascular and neurological toxicity of levobupivacaine has led to its application as a local anaesthetic in a wide variety of specialist applications including peribulbar block for cataract surgery. The aim of this study was to evaluate the efficacy of levobupivacaine 0.5% and to compare block quality vs. ropivacaine 0.75% in peribulbar anaesthesia. METHODS: We examined 208 patients subjected to cataract surgery by phacoemulsification who were randomized into two groups according to the anaesthetic used for peribulbar block, namely levobupivacaine 0.5% or ropivacaine 0.75%, both with the addition of hyaluronidase. Nerve block was carried out by injection of 6 mL of the anaesthetic mixture equally distributed between the inferotemporal and superonasal areas. The success of the block was evaluated by determining the time of motor and sensory onset, akinesia score, times of motor and sensory offset and satisfaction of the patient and surgeon after 24 h. Pre-block, post-block and postoperative intraocular pressure as well as the duration of surgical intervention was also determined. RESULTS: With respect to ropivacaine, levobupivacaine showed a significant reduction (P < 0.001) in the average motor and sensory onset. Both the akinesia score (P < 0.01) and mean motor and sensory offset times were also higher (P < 0.001). Neither the average intervention times nor the satisfaction of the patient/surgeon showed any significant differences between the two groups. CONCLUSIONS: Levobupivacaine (0.5%) has better anaesthetic properties with respect to 0.75% ropivacaine and is well-suited for peribulbar block in cataract surgery.

Minimum local anaesthetic dose (MLAD) of intrathecal levobupivacaine and ropivacaine for Caesarean section.

We determined the minimum local anaesthetic dose (MLAD) of spinal levobupivacaine and ropivacaine for Caesarean section. Ninety women were randomly allocated to two groups and received 3 ml of study solution by a combined spinal/epidural technique. The initial dose was 12 mg for levobupivacaine and 17 mg for ropivacaine groups. To be considered effective, a test solution had to achieve a visual analogue pain score (VAPS) of 30 mm or less at skin incision, uterine incision, birth, peritoneal closure, and at the end of surgery. Effective or ineffective responses determined, respectively, a 0.3 mg decrease or increase of the same drug for the next patient in the same group, using up-down sequential allocation. The MLAD of levobupivacaine was 10.58 mg (CI 95%: 10.08-11.09) and the MLAD of ropivacaine 14.22 mg (CI 95%: 13.67-14.77), using the Dixon and Massey formula. The potency ratio between spinal levobupivacaine and spinal ropivacaine was 1.34.

High volume of subarachnoid levobupivacaine decreases drug requirement in first stage labor analgesia.

AIM: Using the statistic method of sequential allocation, we realized a prospective double-blind study in order to establish the minimum local anesthetic concentration (MLAC) of large intrathecal volume of levobupivacaine, during the first stage labour analgesia in spontaneous and induced laboring women. METHODS: Seventy-five nulliparous, at term, with cervical dilatation <5 cm parturients requesting combined spinal/epidural analgesia, were enrolled. The starting concentration was chosen according to recent literature. Total volume of study solution was 10 ml and efficacy was assessed with a visual analogue pain scale at the height of the uterine contraction. RESULTS: We established that MLAC of levobupivacaine, in 10 ml intrathecal volume, during the first stage of spontaneous and induced labour was 0.0134% and 0.0195%, respectively. No complications occurred during the study and the only side effect was shivering, which is common even in other anesthetic techniques. We produced a very selective sensitive block. Neither sympathetic nor motor block occurred. CONCLUSIONS: Low intrathecally concentration of local anesthetic allows the anesthetist to reduce the total amount of drug and improves not only the differential blockade between motor and sensitive but also between sympathetic and sensitive fibers.

Postpartum cerebral ischaemia after accidental dural puncture and epidural blood patch.

Puerperal women are reported to have a rate of cerebral infarction 13 times greater than non-pregnant females. We report a case of cerebral ischaemia in a 30-yr-old healthy parturient after epidural analgesia for labour, complicated by dural puncture treated with two epidural blood patches. Investigations showed the development of cerebral ischaemia on postpartum day 14. A transcranial Doppler ultrasonography showed vasospasm of the left middle cerebral artery still present at 3-month follow-up. At 1-yr follow-up, the patient had homonymous hemianopsia. We discuss the possible causative mechanism of the cerebral ischaemia in relation to the dural puncture and epidural blood patch.

[Epidural vs general anaesthesia]. / Anestesia epidurale vs generale.

BACKGROUND: Aim of this study is to determine if and how the anaesthesia technique can significantly influence the outcome in patients after major orthopaedic surgery in terms of: patrimony of red blood cells (blood loss and erythropoiesis), incidence of intra and postoperative complications, postoperative pain control and hospital stay. METHODS: 210 patients, ASA physical status I-III, undergoing elective primary total hip replacement were randomly allocated in three groups of 70 patients to receive either epidural anaesthesia (Group EA), general anaesthesia (GA), or epidural anaesthesia integrated with mild general anaesthesia (IA). RESULTS: Data show a significant difference between the amount of pain measured by VRS immediately after surgery: prevalently absent in groups IA (84.3%) and EA (85.7%) and prevalently severe and moderate in group AG (34.3%). The measurement of the basic circulating erythrocyte mass in the first, third and fifth postoperative day, calculated by the Mercuriali formula, which considers blood loss, autologous and homologous transfusions and erythropoiesis, showed that general anaesthesia leads to a significant delay in the resumption of haemopoiesis. This result was attenuated by its combination with epidural anaesthesia. CONCLUSIONS: On the basis of the literature and the results of our study, epidural anaesthesia seems to be the most appropriate technique for patients scheduled for total hip replacement: due to its simpler analgesic cover, its tendency to be associated with a lower incidence of complications in the first 24 hours after surgery. The incidence of relevant hypotension is minor compared to integrated anaesthesia. General anaesthesia produced a significant decrease in postoperative erythropoiesis.

Intraoperative fetal oxygen saturation during Caesarean section: general anaesthesia using sevoflurane with either 100% oxygen or 50% nitrous oxide in oxygen.

BACKGROUND AND OBJECTIVE: The study was designed to evaluate whether the administration of sevoflurane in 100% oxygen for anaesthesia during Caesarean section would improve fetal and neonatal oxygenation compared with the administration of sevoflurane with 50% nitrous oxide in oxygen. METHODS: The randomized, single-blind controlled study examined 24 mothers, ASA I-II, at term undergoing Caesarean section who were allocated to receive sevoflurane in either 100% oxygen (n = 13) or 50% nitrous oxide in oxygen (n= 11). General anaesthesia was induced in both groups with thiopental 4-5 mg kg(-1) followed by succinylcholine 1.5 mg kg(-1) to facilitate tracheal intubation. Parturients received sevoflurane given either in 100% O2 or in a 50:50 nitrous oxide and oxygen mixture, using 0.5-1.0% progressive incremental dosing up to 1.5-2.0 MAC. Non-invasive fetal oxygen saturation was measured between induction to delivery, and umbilical artery and vein PaO2 were evaluated at birth. RESULTS: Intraoperative fetal oxygen saturation increased in all patients after maternal 100% oxygen administration (P < 0.01). Maternal hyperoxygenation significantly increased the umbilical vein and umbilical artery PaO2 and the umbilical artery SaO2 at birth (P < 0.0001). CONCLUSIONS: Maternal hyperoxygenation significantly improves fetal as well as neonatal oxygenation.

Minimum analgesic dose of epidural sufentanil for first-stage labor analgesia: a comparison between spontaneous and prostaglandin-induced labors in nulliparous women.

BACKGROUND: The aim of this prospective, double-blind, sequential allocation study was to compare the effects of spontaneous and prostaglandin-induced labor on the minimum analgesic dose of epidural sufentanil in the first stage of labor. METHODS: Seventy healthy, nulliparous women, at more than 37 weeks' gestation with cervical dilatation from 2 to 4 cm, requesting epidural pain relief in labor were enrolled. The subjects were assigned to two different groups according to whether labor was spontaneous or induced with dinoprostone 0.5 mg. Parturients received 10 ml of the study solution through a lumbar epidural catheter. The initial dose was sufentanil 25 microg, and subsequent doses were determined by the response of the previous patient in the same group using up-down sequential allocation. The analgesic effectiveness was assessed using 100-mm visual analog pain scores. The up-down sequences were analyzed using the method of independent paired reversals and probit regression. RESULTS: The minimum analgesic dose of sufentanil in spontaneous labor was 22.2 microg (95% CI: 19.6, 22.8) and 27.3 microg (95% CI: 23.8, 30.9) in induced labor. The minimum analgesic dose of sufentanil in induced labor was significantly greater (P = 0.0014) than that in spontaneous labor (95% CI difference: 2.9, 9.3) by a factor of 1.3 (95% CI: 1.1, 1.5). CONCLUSION: Prostaglandin induction of labor produces a significantly greater analgesic requirement than does spontaneous labor.

[Levobupivacaine in obstetric analgesia and anaesthesia]. / La levobupivacaina in anestesia ed analgesia ostetrica.

METHODS: Published studies, including abstracts, has been reviewed and summarized. RESULTS: Studies in sheep have demonstrated no significant differences in pharmacokinetic and placental transfer of levobuvacaine when compared with bupivacaine. Clinical studies on cesarean section confirmed similar performance between these two drugs. No differences in onset time, sensory and motor block and efficacy of analgesia have been reported. Two multicentre studies on labor analgesia reported again similar analgesic efficacy with a trend toward less motor block in parturients receiving levobupivacaine. CONCLUSIONS: This review has shown that levobupivacaine has a similar efficacy and a similar maternal fetal safety to that of bupivacaine. Further studies are needed to determine if the chemical properties of the new agent may influence the sensory and motor characteristics of the block.

[Motor block determination for the identification of accidental spinal injection of levobupivacaine: a study on the minimum efficient test-dose (ED50)]. / Determinazione del blocco motorio per l'identificazione della somministrazione spinale accidentale di levobupivacaina: studio sulla minima dose-test efficace (ED50).

BACKGROUND: The aim of this study was to determine the ED50 for the dose of levobupivacaine 0,5% that, if given intrathecally will not cause total spinal anesthesia but will give a reliable and reproducible clinical sign to differentiate intrathecal from epidural injection. METHODS: Thirty women at term undergoing elective cesarean section under a combined spinal-epidural technique (CSE) were enrolled into this sequential allocation study. The dose in each test dose was determined by the response of the previous patient to the higher or lower dose in her test syringe, according to up-down sequential allocation. The exception to this was the first woman in each group, for whom the starting dose was chosen to be 4 mg. The end point was the occurrence of any motor block, in any side, within 5 minutes from intrathecal injection of the test dose. Test dose efficacy was assessed using a modified Bromage scale every minute for 5 minutes. The median effective dose of levobupivacaine was estimated from the up-down sequences using the formula of Dixon and Massey. RESULTS: The MAD of the test dose for levobupivacaine was of 4,8 mg (4,4 to 5,2; 95% C.I.). DISCUSSIONS: This study may help to determine the appropriate dose for a test dose for inadvertent spinal levobupivacaine.

[Prehydratation and anaesthesia in obstetrics: state of the art]. / Preidratazione ed anestesia in obstetricia. Stato dell'arte.

All epidural or spinal techniques using local anaesthetics causes some degree of sympathetic blockade resulting in peripheral vasodilatation and possibly hypotension or reduction in cardiac output. In the practical clinic, administration of fluids intravenously prior spinal and epidural anaesthesia is required to prevent maternal hypotension and fetal hypoxia. We evaluated in this review the efficacy of volume preloading on the incidence of hypotension after spinal or epidural anaesthesia for caesarean delivery. Randomized controlled trials investigating volume preloading before the initiation of obstetric anaesthesia were sought by using MEDLINE (1966-2001). The primary outcome was the incidence of hypotension. Secondary outcomes included: ephedrine use, Apgar scores, umbilical cord pH values, and maternal nausea and vomiting. Crystalloid preload was inconsistent in preventing hypotension, whereas colloid appeared to be effective in all studies. A colloid solution, such as hydro-xyethyl starch (HES) might be preferable considering the capacity to stay intravasculary for a longer period. Few differences in fetal outcomes or maternal nausea and vomiting were reported. Increasing central blood volume by using colloid decreases the incidence of hypotension before loco-regional anaesthesia for cesarean delivery. Implications. We performed a review to determine whether fluid loading reduced the incidence of low blood pressure after spinal or epidural anaesthesia for caesarean delivery. Although no technique totally eliminates the occurrence of hypotension, colloid administration (starch or gelatin containing fluids) was the most effective.

SCS in intractable angina.

Despite a wide range of therapeutic choice in the treatment of angina pectoris, there is a small but increasing population of patients that doesn't benefit of conventional therapy and whose life is invalidated by frequent attack of anginal pain. For this population, nonresponders to drug therapy not suitable for revascularization (coronary bypass surgery, angioplasty), neurostimulation of dorsal column has been described as an effective and safe therapy. The mechanism of action is not completely known, but is safety is sufficiently established. It may become a useful choice in the treatment of patients with intractable angina.

A comparison between low-dose ropivacaine and bupivacaine at equianalgesic concentrations for epidural analgesia during the first stage of labor.

The aim of this study was to evaluate the efficacy, onset and duration of analgesia of two equianalgesic epidural doses of ropivacaine and bupivacaine during the first stage of labor. The study included 190 healthy nulliparous parturients who presented spontaneous onset of labor and required epidural analgesia. They were divided randomly to receive epidural analgesia with an initial dose 0.10% ropivacaine or 0.0625% bupivacaine 20 mL both with the addition of 10 microg of sufentanil. There were no significant differences in onset time, quality of analgesia, maternal hypotension and ability to ambulate. Ropivacaine produced more prolonged analgesia then bupivacaine (89 vs 119 min;P<0.0003). The clinical value of this prolonged analgesia after the first dose needs further evaluation when a continuous infusion technique is used.