The effects of colloid pre-loading on thromboelastography prior to caesarean delivery: hydroxyethyl starch 130/0.4 versus succinylated gelatine.

This prospective, randomized, double-blind study compared the effects on thromboelastography (TEG) of pre-loading with two different colloid fluids prior to spinal anaesthesia for caesarean section. Healthy full-term parturients received either 500 ml 6% hydroxyethyl starch 130/0.4 (HES, n = 25) or 500 ml 4% succinylated gelatine (GEL, n = 25) prior to spinal anaesthesia. TEG parameters including reaction time (r-time), clot formation time (k-time), clot formation rate (α-angle) and maximum amplitude (MA) were measured immediately before and after pre-loading. Both groups had significantly shorter r-time and lower MA after pre-loading. The α-angle was significantly decreased after pre-loading with HES but not with GEL. No significant differences in k-time were induced pre-loading. In conclusion, pre-loading with HES or GEL was associated with a mild hypocoagulable effect in healthy parturients presenting for elective caesarean section; however, all TEG parameters in both groups remained within or very close to the normal range after pre-loading.

The combination of low-dose levobupivacaine and fentanyl for spinal anaesthesia in ambulatory inguinal herniorrhaphy.

This study investigated whether the addition of 25 microg intrathecal fentanyl to levobupivacaine spinal anaesthesia for outpatient inguinal herniorrhaphy allows a sub-anaesthetic levobupivacaine dose to be used. Forty patients were assigned to receive 5 mg levobupivacaine 0.5% mixed with 25 microg fentanyl (group LF) or 7.5 mg levobupivacaine 0.5% (group L). The highest sensory block levels achieved were T7 (range T5 - T9) and T6 (range T4 - T9) in groups LF and L, respectively. The times to two-segment regression, S2 regression, ambulation, urination and discharge were all significantly shorter in group LF than group L. These results indicate that, for outpatient inguinal herniorrhaphy, intrathecal fentanyl combined with low-dose levobupivacaine provides good quality spinal anaesthesia and minimizes the need for intra-operative analgesia. This protocol is well suited for the outpatient setting because it features rapid recovery of full motor power, sensory function and bladder function.

Combination of ultra-low dose bupivacaine and fentanyl for spinal anaesthesia in out-patient anorectal surgery.

This study investigated whether the addition of 25 microg fentanyl to an ultra-low (sub-anaesthetic) dose of intrathecal bupivacaine provides adequate anaesthesia for out-patient anorectal surgery, without increasing side-effects or delaying hospital discharge. Patients were randomly allocated to receive 2.5 mg 0.5% bupivacaine plus 25 microg fentanyl (group BF, n = 18) or 5 mg 0.5% bupivacaine alone (group B, n = 17). There were no significant differences in intra-operative outcomes, but mean recovery and discharge times were significantly shorter in group BF. There were no between-group differences in hypotension, bradycardia or respiratory depression and post-operative complications were comparable, apart from pruritus which was significantly more frequent in group BF. Fewer patients requested analgesic medication in the early post-operative period in group BF than in group B. In conclusion, 25 microg intrathecal fentanyl added to ultra-low dose (2.5 mg) bupivacaine provided good-quality spinal anaesthesia and reduced post-operative analgesic requirement in patients undergoing ambulatory anorectal surgery.

Intrathecal epinephrine in combined spinal-epidural analgesia for labor: dose-response relationship for epinephrine added to a local anesthetic-opioid combination.

BACKGROUND: The purpose was to investigate the dose-response relationship for intrathecally administered epinephrine added to a local anesthetic-opioid combination in combined spinal-epidural analgesia for labor, in order to evaluate analgesia and side-effects. PATIENTS AND METHODS: The subjects were 100 consecutive ASA I or II parturients at 37 weeks' gestation, who received combined spinal-epidural analgesia during labor. Each woman was randomly assigned to one of five groups that received 2-mL volumes of different spinal solutions. The control group received an intrathecal injection of bupivacaine 2.5 mg and fentanyl 25 microg only. The others received epinephrine 12.5, 25, 50 or 100 microg added to this intrathecal regimen. Maternal arterial pressure, heart rate and pain scores were recorded before and 5, 10, 15 and 30 min after intrathecal injection. Level of sensory blockade, motor blockade score, duration of intrathecal analgesia, side effects, fetal heart rate, and 1- and 5-min Apgar scores were also assessed. RESULTS: Compared to the control group, all four epinephrine groups had significantly longer duration of intrathecal analgesia, but the durations were similar. The frequencies of side effects were similar in all five groups. CONCLUSION: The results suggest that adding epinephrine to a combination of standard intrathecal doses of bupivacaine and fentanyl in combined spinal-epidural analgesia for labor significantly prolongs spinal analgesia. Of the four epinephrine doses tested, the lowest one (12.5 microg) was optimal for this clinical setting.

Fatal hydrothorax due to misplacement of a nasoenteric feeding tube.

Blind nasoenteric intubation was attempted in a patient with chronic parkinsonism. The tube was inadvertently misplaced and penetrated the left pleural cavity. The next day, the patient developed cardiopulmonary arrest during dietary supplement infusion. This complication ultimately led to the patient's death. We have reviewed the known complications of nasoenteric tube placement and conclude that difficult insertion in patients at risk from tube misplacement should be followed by chest radiography to confirm the correct placement of the tube before nutritional support is started.