The influence of a bupivacaine and fentanyl epidural infusion after epidural fentanyl in patients allowed to ambulate in early labor.

UNLABELLED: Epidural fentanyl after a lidocaine and epinephrine test dose provides adequate analgesia and allows for ambulation during early labor. This study was designed to determine the influence of an epidural infusion of bupivacaine plus fentanyl administered after initiation of epidural labor analgesia with fentanyl. Specifically, we evaluated whether there is an increase in motor block or an increased time to request for further analgesic medication. Fifty-one laboring primigravid women at <5 cm cervical dilation who requested epidural analgesia were enrolled. After a 3-mL epidural test dose of 1.5% lidocaine with epinephrine (5 microg/mL), patients received fentanyl 100 microg via the epidural catheter. They then randomly received either an infusion (10 mL/h) of 0.0625% bupivacaine with fentanyl (3 microg/mL) or an infusion of preservative-free saline. After the administration of the initial analgesic, pain scores and side effects were recorded for each patient at 10, 20, and 30 min, every 30 min thereafter, and at the time of request for additional analgesic medication, by an observer blinded to the technique used. There were no demographic differences between the two groups. The mean duration of analgesia (time from initial dose to request for additional analgesia) was increased in the group that received a continuous infusion of bupivacaine and fentanyl compared with the Saline group (198 +/- 86 vs 145 +/- 50 min; P < 0.009). Side effects were similar between the two groups. No patient in either group experienced any detectable motor block. Fourteen patients chose to ambulate in the Saline group, and 12 patients chose to ambulate in the Infusion group. In early laboring patients, a continuous infusion of 0.0625% bupivacaine infusion with fentanyl (3 microg/mL) prolonged the duration until top-up was required, after epidural fentanyl 100 microg after a lidocaine and epinephrine test dose, and did not cause any clinically detectable motor block. IMPLICATIONS: A 0.0625% bupivacaine and fentanyl (3 microg/mL) infusion, when added to epidural fentanyl (100 microg), prolongs the analgesic duration without increasing motor block in women in early labor.

Anesthetic management of the exit (ex utero intrapartum treatment) procedure.

The EXIT (ex utero intrapartum treatment) procedure is used to maintain fetal-placental circulation during partial delivery of a fetus with a potentially life-threatening upper airway obstruction. We performed the EXIT procedure on a fetus with a large intra-oral cyst. Sevoflurane was used as the anesthetic because of its rapid titratability. Sevoflurane provided excellent maternal and fetal anesthesia. Modifications to previously described monitoring techniques for the EXIT procedure were also used.

A comparison of the Bullard laryngoscope versus the flexible fiberoptic bronchoscope during intubation in patients afforded inline stabilization.

STUDY OBJECTIVE: To compare the Bullard laryngoscope (BL) with the flexible fiberoptic bronchoscope (FFB) in a cervical spine injury model, using inline stabilization. DESIGN: Randomized clinical trial. SETTING: Main operating room of a tertiary care hospital. PATIENTS: 50 adult, ASA physical status I, II, and III patients undergoing an elective general anesthetic. INTERVENTIONS: Each patient's trachea was intubated with both techniques. Cricoid pressure was applied to half of the study patients. MEASUREMENTS: The time for laryngoscopic view and the time to intubation were recorded for each technique. The effects of cricoid pressure on laryngoscopic view and intubation time were determined. MAIN RESULTS: The times for laryngoscopy and intubation were longer in the FFB group than in the BL group (p < 0.004). There was a significantly lower success rate of laryngoscopy view in the FFB group in the presence of cricoid pressure (15 of 25 patients, or 60%) than either of the BL groups or the FFB no-cricoid pressure group. CONCLUSIONS: The BL is more reliable, quicker, and more resistant to the effects of cricoid pressure than is the FFB.

Comparison of wire reinforced tubes with warmed standard tubes to facilitate fiberoptic intubation.

STUDY OBJECTIVE: To compare the ease of insertion of a warmed standard tracheal tube to that of a wire reinforced tracheal tube when placed over a flexible fiberoptic bronchoscope. DESIGN: Randomized controlled trial. SETTING: Tertiary care hospital. PATIENTS: 50 patients undergoing elective general anesthesia. INTERVENTIONS: Patients' tracheas were intubated with a flexible fiberoptic bronchoscope and had either a standard or wire-reinforced tracheal tube inserted. If resistance was met, the tube was withdrawn, rotated, and readvanced. This was repeated two times. If unsuccessful, the flexible fiberoptic bronchoscope was removed, and intubation was attempted with the other type of tracheal tube. MEASUREMENTS: The ability to advance the tracheal tube was determined. MAIN RESULTS: There were no demographic differences between the two groups. There was a similar ease of advancement of the two tracheal tubes. CONCLUSIONS: When performing elective flexible fiberoptic bronchoscopy for intubation, we recommend using the less expensive warmed standard tracheal tube.

EPR and NMR spectroscopic studies of [MoL2(MeC identical to CMe)Cp]z (L = P-donor ligand, z = 0 and 1): fluxionality in a metal-alkyne redox pair.

Variable temperature NMR and EPR spectroscopic studies provide rates and activation parameters for alkyne rotation and oscillation, respectively, in the fluxional redox pair [Mo(P(OMe)3)2(MeC identical to CMe)Cp][BF4] (diamagnetic) and [Mo(P(OMe)3)2(MeC identical to CMe)Cp] (paramagnetic).

Control over directional metal-metal charge transfer in cyanide-bridged dimanganese complexes: effects of mu-CN linkage isomerism and ancillary ligand set.

Synthesis and characterisation of cyano-bridged complexes of the form [(eta-C5R4Me)L(ON)Mn(mu-XY)Mn(CO)2-L'(dppm)]z (X,Y = C,N; z = 1-3) shows that systematic variation of the orientation of the CN bridge and the nature and geometric arrangement of the ancillary ligands affords control of the direction and energy of metal-metal charge transfer in the mixed valence dications.

Postoperative analgesic effects of celecoxib or rofecoxib after spinal fusion surgery.

UNLABELLED: Nonsteroidal antiinflammatory drugs are recommended for the multimodal management of postoperative pain and may have a significant opioid-sparing effect after major surgery. The analgesic efficacy of the cyclooxygenase-2 nonsteroidal antiinflammatory drugs, celecoxib and rofecoxib, have not been evaluated after major orthopedic surgery. This study was designed to determine whether the administration of a preoperative dose of celecoxib or rofecoxib to patients who have undergone spinal stabilization would decrease patient-controlled analgesia (PCA) morphine use and/or enhance analgesia. We evaluated 60 inpatients undergoing spine stabilization by one surgeon. All patients received PCA morphine. The patients were divided into three groups. Preoperatively, they were given oral celecoxib 200 mg, rofecoxib 50 mg, or placebo. The outcome measures included pain scores and 24-h morphine use at six times during the first 24 postoperative h. The total dose of morphine and the cumulative doses for each of the six time periods were significantly more in the placebo group than in the other two groups. The morphine dose was significantly less in five of the six time intervals in the rofecoxib group compared with the celecoxib group. The pain scores were significantly less in the rofecoxib group than in the other two groups at two of the six intervals, and less than the placebo group in an additional interval. Although both rofecoxib and celecoxib produce similar analgesic effects in the first 4 h after surgery, rofecoxib demonstrated an extended analgesic effect that lasted throughout the 24-h study. We thus recommend that rofecoxib be used as a preoperative component of pain management that includes PCA morphine in patients undergoing spine stabilization surgery. IMPLICATIONS: The cyclooxygenase-2-specific nonsteroidal antiinflammatory drugs, celecoxib and rofecoxib, both demonstrate an opioid-sparing effect after spinal fusion surgery. Celecoxib resulted in decreased morphine use for the first 8 h after surgery, whereas rofecoxib demonstrated less morphine use throughout the 24-h study period.

Comparison of epidural fentanyl versus epidural sufentanil for analgesia in ambulatory patients in early labor.

UNLABELLED: Epidural sufentanil, after a lidocaine and epinephrine test dose, provides adequate analgesia and allows for ambulation during early labor. Epidural fentanyl has not been evaluated in this setting. The current study was designed to determine whether there is an analgesic difference between epidural fentanyl and epidural sufentanil in laboring patients. Forty-six laboring nulliparous women, at <5-cm cervical dilation, who requested epidural analgesia were enrolled. After a 3-mL test dose of lidocaine with epinephrine, patients were randomized to receive either sufentanil 20 microg or fentanyl 100 microg. After administration of the analgesic, pain scores and side effects were recorded for each patient at 5, 10, 15, 20, and 30 min and every 30 min thereafter, by an observer blinded to the technique used. There were no demographic differences between the two groups. Pain relief was rapid for all patients. The mean durations of analgesia were similar between the sufentanil group (138 +/- 50 min) and the fentanyl group (124 +/- 42 min). Side effects were similar between the two groups. In early laboring patients, epidural fentanyl 100 microg, after a lidocaine and epinephrine test dose, provides analgesia comparable to that of sufentanil 20 microg. IMPLICATIONS: In early laboring patients, epidural fentanyl 100 microg, after a lidocaine and epinephrine test dose, provides analgesia comparable to that of sufentanil 20 microg.

Sumatriptan in patients with postdural puncture headache.

OBJECTIVE: To determine the efficacy of sumatriptan in the management of patients presenting for an epidural blood patch for the management of postdural puncture headache. BACKGROUND: Postdural puncture headache can be quite severe, requiring invasive therapy (ie, epidural blood patch). Sumatriptan has been used successfully in patients with postdural puncture headache, however, its use has not been investigated in a controlled fashion. METHODS: Ten patients with postdural puncture headache presenting for an epidural blood patch were given either saline or sumatriptan subcutaneously. The severity of the headache was evaluated at baseline and 1 hour following injection. If the headache remained severe, an epidural blood patch was performed. RESULTS: Only one patient in each group received relief from the injection. CONCLUSIONS: We do not recommend sumatriptan in patients who have exhausted conservative management of postdural puncture headache.

The adult Bullard laryngoscope as an alternative to the Wis-Hipple 1(1/2) in paediatric patients.

This prospective, randomized study was undertaken to compare the adult Bullard laryngoscope (BL) with the Wis-Hipple laryngoscope (WhL) in paediatric patients with regards to laryngeal view and time to intubation, and whether its efficacy was related to age or weight. Fifty patients scheduled for general anaesthesia between the ages of 1 and 5 years were examined. Patients were randomized into two groups: one group had an initial laryngoscopy via the WhL and then had a laryngoscopy and intubation using the BL; the second group had an initial laryngoscopy with the BL and then had a laryngoscopy and intubation using the WhL. The laryngeal view, attempts at intubation, time to intubation and the reason for any difficulty with intubation were recorded. Correlation was then sought relating attempts and time to intubation with age, and weight. Mean time to intubation was 20 +/- 6 s in the WhL group and 26 +/- 9 s in the BL group (P < 0.02). The majority of the patients had similar laryngeal views in both groups; three patients had a superior view with the BL. Failed intubations occurred in two BL patients; the tracheas were both intubated with the WhL. In one patient, intubation was not possible with the WhL but it was successful with the BL. Multiple passes of the tube off the BL most frequently occurred because of right aryepiglottic fold contact or anterior vocal cord contact. The latter appears to be more problematic when the adult BL is used in the paediatric population. No relationship was found between the time to intubation and age or weight. In an occasional child, the BL provides a superior laryngeal view and provides a means for a successful intubation when a failure with the WhL occurs. Although intubation of children aged 1-5 years takes longer with a BL than a WhL, the adult BL complemented the WhL laryngoscope in paediatric patients.

An evaluation of the cuffed oropharyngeal airway for elective pediatric anesthesia.

STUDY OBJECTIVE: To evaluate the usefulness in pediatric patients of the cuffed oropharyngeal airway (COPA), an airway device with an inflatable cuff around its distal portion, and which provides airway patency in the majority of anesthetized adult patients. DESIGN: Prospective evaluation. SETTING: Pediatric operating room of a tertiary-care medical center. PATIENTS: 50 anesthetized ASA physical status I pediatric patients, under 6 yr of age undergoing elective surgery. INTERVENTIONS: Patients were fitted with a size 7 COPA placed following anesthetic induction. If an adequate airway was not obtained, a size 8 COPA was placed. If an adequate airway was not obtained despite repositioning the size 8, the COPA was considered failed. MEASUREMENTS AND MAIN RESULTS: The ease of insertion and ability to manage the airways were evaluated. Complications were evaluated on insertion, during maintenance, and upon awakening. The ability to positive pressure ventilate via the COPA was assessed. The size 7 COPA obtained an initial fit in 38 (76%) of the patients. Nine patients were managed with a size 8 COPA. The COPA was unsuccessful in 3 (6%) patients. Laryngospasm occurred in three patients. Blood was not visible on any of the COPAs. Positive pressure ventilation was achieved with 30 +/- 7 cm H(2)O pressure. CONCLUSIONS: The results using the COPA in pediatric patients seem to parallel the experience of using larger sizes in adult patients.

Effect of epidural clonidine added to epidural sufentanil for labor pain management.

Labor analgesia with intrathecal sufentanil has been shown to be prolonged by the addition of intrathecal clonidine. The current study was designed to determine if epidural clonidine would prolong labor analgesia provided by epidural sufentanil. Forty laboring primiparous women at less than 5 cm cervical dilation requesting epidural analgesia were enrolled. Following a 3 mL test dose of lidocaine with epinephrine, patients were randomized to receive 10 mL of either sufentanil 20 microg (S) or sufentanil 20 microg with clonidine 75 microg (SC). After administration of the analgesic, pain scores and side-effects were recorded for each patient at 5, 10, 15, 20 and 30 min, and every 30 min thereafter, by an observer blinded to the technique used. There were no demographic differences between the two groups. Pain relief was rapid for all patients. The mean duration of analgesia was similar between the S group (153 +/- 78 min) and the SC group (178 +/- 55 min). Side-effects were similar between the two groups. There was no difference between the two groups in time from sufentanil administration to delivery, incidence of operative or assisted delivery, or cervical dilation at the time of redose. For early laboring patients, epidural sufentanil 20 microg after a lidocaine test dose provides analgesia comparable to that of sufentanil 20 microg with clonidine 75 microg; there was no significant difference in analgesic duration between the two groups.

Use of clonidine as a component of the peribulbar block in patients undergoing cataract surgery.

BACKGROUND AND OBJECTIVES: This study was designed to determine whether administration of clonidine as a component of a peribulbar block enhanced analgesia increased sedation, improved akinesia, or decreased intraocular pressure. METHODS: A randomized, double-blinded study was undertaken at a University-affiliated tertiary care hospital. Forty outpatients undergoing unilateral cataract surgery by a single surgeon (J.P.) under peribulbar blockade were evaluated. Patients received either 100 microg (1 mL) clonidine or 1 mL preservative-free normal saline mixed with the local anesthetic (7 mL 1% preservative-free lidocaine). A Honan adapter was applied for 10 minutes after block placement. The outcome measures included sedation scores, intraocular pressure (IOP) before and after peribulbar block, need for supplemental block, 24-hour analgesic requirement, and patient satisfaction. RESULTS: There were no differences between groups with respect to pain, sedation, or satisfaction scores. There was no difference with respect to onset of akinesia. This study revealed no significant difference in baseline IOP and postperibulbar IOP. CONCLUSIONS: Clonidine did not alter, in any appreciable way, the perioperative course for patients undergoing cataract operations. We do not recommend clonidine as a component of a peribulbar block in patients undergoing cataract extraction operations.