The influence of epidural needle bevel orientation on spread of sensory blockade in the laboring parturient.

UNLABELLED: Both asymmetrical sensory blockade and dural puncture are undesirable outcomes of epidural analgesia. Identifying the epidural space with the needle bevel oriented parallel to the longitudinal axis of the patient's back limits the risk of headache in the event of dural puncture. However, rotating the bevel to direct a catheter cephalad may risk dural puncture. We prospectively studied the effects of needle rotation on the success of labor epidural analgesia and on the incidence of dural puncture. One hundred sixty ASA physical status I or II laboring parturients were randomly assigned to one of four groups. The epidural space was identified with the bevel of an 18-gauge Hustead needle directed to the patient's left. It was then rotated as follows: Group 0 = no rotation, final bevel orientation left (n = 39); Group 90 = rotation 90 degrees clockwise, bevel cephalad (n = 43); Group 180 = rotation 180 degrees clockwise, bevel right (n = 36); Group 270 = rotation 270 degrees clockwise, bevel caudad (n = 42). A single-orifice catheter was inserted 3 cm, and analgesia was induced in a standardized fashion. Dural puncture was evenly distributed among the groups (4.4%). There were more dermatomal segments blocked, fewer one-sided blocks, and more patients comfortable at 30 min with the needle bevel directed cephalad. Using a catheter inserted through a needle oriented in the cephalad direction increases the success of epidural analgesia. IMPLICATIONS: This prospective study shows that an epidural catheter inserted through a needle oriented in the cephalad direction increases the success of labor analgesia in the parturient. Carefully rotating the needle cephalad does not increase the risk of dural puncture, intravascular catheters, or failed blocks.

Intrathecal sufentanil dose response in nulliparous patients.

BACKGROUND: Intrathecal sufentanil provides effective analgesia during the first stage of labor. A range of doses has been reported to provide adequate pain relief. This study determined the dose of intrathecal sufentanil that produced acceptable pain relief in 50% of nulliparous patients (ED50) who requested labor analgesia. METHODS: With institutional review board approval, 50 nulliparous patients requesting spinal opioid labor analgesia were enrolled into this prospective, randomized, double-blinded study. Each patient was in spontaneous labor at <5 cm cervical dilation. Patients received one of the following doses of intrathecal sufentanil: 1, 2, 3, 5, or 10 microg in 3 ml preservative-free saline (n = 10 for each dose). Pain, pain relief, hemodynamic, respiratory, and side effect data were collected at times 0, 2, 5, 10, 15, 20, 25, and 30 min. Probit analysis of the number of patients in each group who requested additional pain medicine at 30 min was used to determine the ED50. RESULTS: The groups were demographically similar. The ED50 of intrathecal sufentanil was 1.8 microg (SE, 0.6 microg; 95% CI, 2.96 to 0.54 microg). The incidence of side effects was similar among the groups. CONCLUSIONS: This is the first study to determine the ED50 of intrathecal sufentanil in spontaneously laboring nulliparous patients. As dose-response curves are determined for other labor analgesics, future studies can compare equianalgesic doses or dose combinations.

Baricity, needle direction, and intrathecal sufentanil labor analgesia.

BACKGROUND: Intrathecal sufentanil relieves labor pain but centrally mediated side effects are common. Preventing rostral spread of intrathecal sufentanil should limit these side effects. Both direction of the lateral opening of a pencil-point needle and drug baricity modify the spread of intrathecal local anesthetics. This randomized, prospective, double-blind study examines the effects of these variables on intrathecal sufentanil labor analgesia. METHODS: Forty laboring, full-term parturients, whose cervixes were dilated less than 5 cm and who requested analgesia for labor were enrolled. Combined spinal epidural analgesia was induced in patients in the sitting position. They were allocated to receive 10 micrograms intrathecal sufentanil diluted with either normal saline or dextrose with the aperture of the pencil-point needle directed cephalad or caudad during drug injection. Thus there were four groups of ten patients: dextrose up, dextrose down, saline up, and saline down. Sufentanil was diluted with normal saline to a concentration of 10 micrograms/ml. The study drug was made by mixing 1 ml sufentanil solution with either 1 ml 10% dextrose or 1 ml normal saline. Visual analog scores for pain, pruritus, nausea, and pain relief were recorded before and 5, 10, 15, and 30 min after drug injection. RESULTS: Baricity, but not needle orientation, influenced pain relief and pruritus. Sufentanil in dextrose produced less itching but also less analgesia. Nine of 20 women in the dextrose groups compared with 1 of 20 in the saline groups requested additional analgesia by 30 min. CONCLUSIONS: Little or no labor analgesia developed for patients receiving sufentanil with dextrose. A supraspinal action may contribute to intrathecal sufentanil's analgesic efficacy.

Airway sealing pressures of the laryngeal mask airway in pediatric patients.

STUDY OBJECTIVES: To determine if the laryngeal mask airway (LMA) seal is maintained during surgery, to evaluate the safety of an LMA leak test, and to determine the time course of the increase in LMA cuff pressure in vivo in the presence of nitrous oxide (N2O). STUDY DESIGN: Descriptive clinical study. SETTING: University teaching hospital. PATIENTS: 78 ASA Physical Status I and II pediatric patients, aged 3 months to 17 years, undergoing general anesthesia with an LMA; 14 patients were studied on two occasions approximately 2 months apart. INTERVENTIONS: The airway pressure at which the LMA seal was broken (leak pressure) was determined immediately following insertion of the LMA and at the end of surgery. In 17 patients, the LMA cuff pressure was continuously measured during surgery, during which 67% N2O was administered. The mean duration of surgery was 29.5 minutes. MEASUREMENTS AND MAIN RESULTS: The LMA leak pressure was determined by closing the circuit popoff valve and recording the pressure at which gas was first heard to escape around the LMA at the mouth. The LMA cuff pressure was determined by connecting the check valve of the LMA pilot balloon to a sphygmomanometer. The elastance of the LMA was determined from the slopes of the regression lines of pressure versus volume for the various sized LMAs in vitro (Sizes 1-4) and in vivo (sizes 2 and 2 1/2). The initial LMA leak pressure was 25.9 cm H2O, and it increased to 31.2 cm H2O during surgery (p < 0.001). 146 leak tests were performed without causing gastric dilatation or LMA dislodgement. The mean LMA cuff pressure increased during surgery from 106.2 mmHg to 132.8 mmHg (p < 0.001), a pressure increase that corresponds to a volume increase of 1.4 ml. CONCLUSIONS: The LMA leak test can be safely performed. The airway seal provided by the LMA is well maintained during surgery. The increase in LMA cuff pressure during surgery in the presence of N2O is small and probably is not a cause for clinical concern. If positive pressure is to applied in the presence of an LMA, one should limit this pressure to below the LMA leak pressure so as to lower the risk of inflating the stomach with gas that may than leak around the LMA.