The effect of force applied to the left paratracheal oesophagus on air entry into the gastric antrum during positive-pressure ventilation using a facemask.

Cricoid force is widely applied to decrease the risk of pulmonary aspiration and gastric antral insufflation of air during positive-pressure ventilation, yet its efficacy remains controversial. We compared manual oesophageal compression at the low left paratracheal and cricoid levels for the prevention of gastric antral air insufflation during positive-pressure ventilation by facemask in patients scheduled for elective surgery under general anaesthesia. After gaining written consent, participants were randomly allocated by sealed envelope to one of three groups: oesophageal compression by 30 N paratracheal force (paratracheal group); oesophageal compression by 30 N cricoid force (cricoid group); or no oesophageal compression (control group). Gastric insufflation of air was assessed before and after positive-pressure ventilation by ultrasound measurement of the antral cross-sectional area and/or presence of air artefacts in the antrum. The primary outcome measure was the proportion of participants with ultrasound evidence of gastric insufflation. We recruited 30 patients into each group. Before facemask ventilation, no air artefacts were visible in the antrum in any of the participants. After facemask ventilation of the participant's lungs, no air artefacts were seen in the paratracheal group, compared with six subjects in the cricoid group and eight subjects in the control group (p = 0.012). Our results suggest that oesophageal compression can be achieved by the application of manual force at the low left paratracheal level and that this is more effective than cricoid force in preventing air entry into the gastric antrum during positive-pressure ventilation by facemask.

Intrathecal ropivacaine for ambulatory surgery.

BACKGROUND: The rationale of this study was to evaluate intrathecal ropivacaine for ambulatory surgery. METHODS: One hundred fifty patients with American Society of Anesthesiologists physical status 1 scheduled for knee arthroscopy were studied. Patients were randomly assigned to receive 4 ml of one of five isobaric intrathecal solutions: Patients in group 1 (n = 30) received 8 mg of bupivacaine; patients in group 2 (n = 30) received 8 mg ropivacaine; patients in group 3 (n = 30) received 10 mg ropivacaine; patients in group 4 (n = 30) received 12 mg ropivacaine; and patients in group 5 (n = 30) received 14 mg ropivacaine. The level and duration of sensory anesthesia were recorded along with the intensity and duration of motor block. Patients were interviewed to identify transient neurologic symptoms. RESULTS: Intrathecal ropivacaine 10 mg produced shorter sensory anesthesia and motor blockade than bupivacaine 8mg (152 +/- 44 min and 135 +/- 41 min vs. 181 +/- 44 min and 169 +/- 52 min, mean +/- SD; P < 0.05). However, the quality of intraoperative analgesia was significantly lower in the 10-mg ropivacaine group (P < 0.05). Ropivacaine 12 mg produced sensory and motor block almost comparable to bupivacaine 8 mg. Ropivacaine 14 mg produced sensory and motor block comparable to ropivacaine 12 mg but significantly increased the time to void. No sign of transient radicular irritation were noted. CONCLUSION: Intrathecal ropivacaine 12 mg is approximately equivalent to bupivacaine 8 mg. At this dose, ropivacaine offers no significant advantage compared with bupivacaine.

Intrathecal clonidine combined with sufentanil for labor analgesia.

BACKGROUND: Intrathecal sufentanil provides rapid-onset and complete analgesia for the first stage of labor. The dose required to produce this effect can be associated with maternal respiratory depression, hypotension, nausea, or pruritus. Because clonidine potentiates the analgesic effects of opioids without increasing their side effects, the authors wanted to determine the efficacy of low doses of intrathecal clonidine (15 and 30 microg) combined with sufentanil. METHODS: Ninety-eight parturient requesting labor analgesia were studied. In a combined spinal-epidural technique, patients were randomly assigned to receive one of the following intrathecal solutions: either 15 microg clonidine (n = 10); 30 microg clonidine (n = 10); 2.5 microg sufentanil (n = 13); 5 microg sufentanil (n = 13); 2.5 microg sufentanil and 15 microg clonidine (n = 13); 2.5 microg sufentanil and 30 microg clonidine (n = 13); 5 microg sufentanil and 15 microg clonidine (n = 13); or 5 microg sufentanil and 30 microg clonidine (n = 13). Visual analog scores for pain, blood pressure, heart rate, sensory levels, incidence of nausea and pruritus, and motor blockade, and maternal and cord blood concentrations of clonidine were recorded. RESULTS: Patients receiving 30 microg intrathecal clonidine with 2.5 or 5 microg intrathecal sufentanil had significantly longer-lasting analgesia (145 +/- 36 and 145 +/- 43 min vs. 104 +/- 35 for those receiving 5 microg intrathecal sufentanil alone). Clonidine levels were undetectable in maternal serum. CONCLUSIONS: Thirty micrograms of intrathecal clonidine combined with 2.5 or 5 microg intrathecal sufentanil significantly increased the duration of analgesia during the first stage of labor without adverse maternal or fetal effects.

Ambulatory combined spinal-epidural analgesia for labor. Influence of epinephrine on bupivacaine-sufentanil combination.

BACKGROUND AND OBJECTIVES: Subarachnoid sufentanil 5 micrograms during labor is known to have variable results. However, subarachnoid sufentanil 5 micrograms plus bupivacaine 1 mg provides good quality labor analgesia of 100 minutes' average duration. The objective of this study was to examine the effects of adding epinephrine 25 micrograms to this mixture. METHODS: Forty-two parturients with less than 5 cm cervical dilation participated in this double-blind, randomized study. A combined spinal-epidural technique was used for subarachnoid administration of sufentanil 5 micrograms and bupivacaine 1 mg with or without epinephrine 25 micrograms. Analgesia was assessed by visual analog scores. Time elapsed until first request for additional analgesia, blood pressure, heart rate, sensory levels, motor block, and incidence of pruritus, nausea, and sedation were noted. RESULTS: Addition of epinephrine prolonged the duration of analgesia from 103.8 +/- 28.2 minutes to 142 +/- 54.3 minutes and lowered the median cephalad level of sensory block from T3 to T6. The incidence of side effects was similar in both groups, as was the motor performance; 19 patients were able to ambulate in each group. CONCLUSIONS: This minimal bupivacaine-sufentanil-epinephrine mixture allows high-quality analgesia of 142 +/- 54.3 minutes' duration, with a low sensory block level and no motor block. However, hypotension can occur as a late side effect.

Fatal Capnocytophaga canimorsus septicemia in a previously healthy woman.

A previously healthy 47-year-old woman presented to the emergency department with septic shock five days after a small dog bite on the dorsum of her hand. Capnocytophaga canimorsus was isolated from blood cultures. Despite intensive therapy, multiple organ failure developed, and the patient died 27 days after admission. Characteristics of Capnocytophaga (formerly CDC group Dysgonic Fermenter-2) infection are briefly discussed. This unusual outcome in a previously healthy patient and the need for careful management of dog bite wounds, even if initially very small, is emphasized.

Intensive care management of Guillain-Barré syndrome during pregnancy.

A particularly severe case of Guillain-Barré syndrome occurring during pregnancy is reported. The therapeutic approach including plasmapheresis, ventilation, analgesia, sedation, metabolic requirements and heparin therapy is discussed with the consequences on foetal development and the early days of life.

Guillain-Barre syndrome after obstetrical epidural analgesia.

Guillain Barre Syndrome (GBS) occurred 24 hours post-partum following an obstetrical epidural anesthetic (OEA) procedure. Clinical diagnosis was confirmed by cerebrospinal fluid (CSF) findings and nerve conduction velocity studies. GBS is an immune mediated process. Because of short latency between the onset of symptoms and the performance of the epidural block, a cause and effect relationship between epidural block and GBS in this patient is unlikely.