Anesthetic management of a parturient with type III Klippel-Feil syndrome.

Klippel-Feil syndrome is believed to occur from failure of normal segmentation of cervical somites during gestation. We present the case of a 38-year-old primiparous woman with type III Klippel-Feil syndrome for elective cesarean delivery. Our patient had a short webbed neck, short stature, limited neck flexion and extension, and thoraco-lumbar abnormalities. A multidisciplinary approach, involving obstetrics, medical subspecialties, anesthesiology, otolaryngology, and radiology, were utilized to evaluate and manage this patient. Pulmonary function testing revealed a restrictive defect, but transthoracic echocardiography was normal without pulmonary hypertension. We planned a combined spinal-epidural technique; however, only the epidural technique was obtained. Cesarean delivery was commenced with favorable maternal and fetal outcomes. Post-operative pain management was provided with intravenous morphine patient-controlled analgesia.

Multiport epidural catheters: does the air test work?

BACKGROUND: Multiport epidural catheters are popular; however, the reliability of the air test has not been evaluated with this catheter design. The authors determined the effectiveness of aspirating for blood and the air test in detecting intravascular multiorifice epidural catheters. METHODS: Three hundred women in labor underwent placement of a blunt-tip, three-hole, 20-gauge, lumbar epidural catheter. If there were no signs of spinal anesthesia, 3 ml lidocaine or bupivacaine was injected and the patient was observed for signs of spinal anesthesia. If there were no signs of spinal anesthesia, the authors injected 1 ml air through the epidural catheter while listening to the maternal precordium using a Doppler fetal heart rate monitor. Catheters through which blood was aspirated were air-tested and replaced. Patients with air-test-positive, blood-aspiration-negative catheters received 100 mg lidocaine through the catheter and were questioned about toxicity symptoms. The authors injected bupivacaine-fentanyl through aspiration-negative,air-test-negative catheters and recorded the sensory analgesic level 20 min later. RESULTS: The authors aspirated cerebrospinal fluid through one catheter and documented intravascular placement in 11 catheters. Results of the air test and blood aspiration were positive for eight catheters. Blood could not be aspirated from one air-test-positive catheter; perioral numbness developed in the patient after lidocaine injection. Blood was freely aspirated from two air-test-negative catheters. In the remaining 288 catheters, bupivacaine-fentanyl injection produced epidural analgesia in 279 patients and no effect in 9 patients. CONCLUSIONS: The authors obtained false-negative results with both catheter aspiration and the air test. Fractionating the local anesthetic dose is important when using multiorifice epidural catheters.

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.

The dermatomal spread of epidural bupivacaine with and without prior intrathecal sufentanil.

Clinicians often use a technique combining intrathecal sufentanil and epidural bupivacaine to provide labor analgesia. This study determines the effect of 27- or 24-gauge dural puncture and intrathecal sufentanil 10 micrograms on the dermatomal spread of epidural bupivacaine. Healthy laboring women received no dural puncture (n = 77) (no puncture group [NPG]) or dural puncture with a 27-gauge Whitacre needle (n = 33) or a 24-gauge Sprotte needle (n = 37) and intrathecal sufentanil 10 micrograms (dural puncture group [DPG]) before epidural injection of 13 mL bupivacaine 0.25%. More dermatomes were anesthetized in the DPG, 16.6 +/- 7.5 vs 13.6 +/- 6.6 in the NPG (P < 0.02). More patients in the DPG had sensory blockade T-4 or higher (17 of 70 DPG patients vs 8 of 77 NPG patients; P < 0.05). No patient in either group showed clinical evidence of respiratory compromise. In conclusion, epidural bupivacaine anesthetized more dermatomes when administered 104 +/- 42 min after dural puncture and intrathecal sufentanil 10 micrograms than when given without prior dural puncture and intrathecal injection.

Ilioinguinal iliohypogastric nerve blocks--before or after cesarean delivery under spinal anesthesia?

Preoperative local anesthetic blockade of somatosensory pathways involved with skin incision and other noxious perioperative stimuli may "preempt" or attenuate the postoperative pain response. Since the Pfannenstiel incision lies within the L1 dermatome, bilateral ilioinguinal, iliohypogastric nerve blocks (IINBs) should provide analgesia after low transverse cesarean section. We designed this study to compare the analgesic effect of IINBs placed before or after cesarean delivery. Forty-six patients undergoing cesarean delivery with spinal anesthesia were enrolled. Patients were randomly assigned to one of three groups: Before, After, or None. Bilateral IINBs were placed with 0.5% bupivacaine, 10 mL to each side. Twenty-two patients had IINBs placed before surgery (11 failed blocks), 12 had blocks placed after surgery, and 12 had no block. Morphine, through a patient-controlled analgesia (PCA) pump, provided additional postoperative analgesia. A blinded observer assessed 24-h morphine use as well as patient satisfaction and pain scores ("incisional" and "overall") for 96 h. Although there were no consistent differences in pain scores among the groups, patients in the After group occasionally reported more pain than those in the Before and None groups. Patient satisfaction and morphine use did not differ among the groups. We conclude that there is no benefit to ilioinguinal nerve blocks, either before or after surgery, in patients who receive spinal anesthesia for elective cesarean delivery. Our finding of increased pain in the After group is perplexing and requires confirmation.

Do patient variables influence the subarachnoid spread of hyperbaric lidocaine in the postpartum patient?

BACKGROUND AND OBJECTIVES: Age, height, weight, body mass index (weight/height2), and vertebral column length may affect the subarachnoid spread of local anesthetics. Little information exists concerning the relationship between these variables and the spread of hyperbaric lidocaine. The authors studied the influence of patient demographics on the block produced by hyperbaric lidocaine in women undergoing postpartum tubal ligation. METHODS: Within 48 hours of vaginal delivery, the authors studied 44 ASA class 1-2 women agreeing to spinal anesthesia for postpartum tubal ligation. Before induction of anesthesia, the authors weighed each patient, measured her height and vertebral column length, and calculated body mass index. In a standardized manner, the authors induced spinal anesthesia with 5% lidocaine 75 mg. An observer, blinded to the measured variables, evaluated loss-of-temperature sensation and loss-of-sensation of sharpness to pinprick bilaterally every 5 minutes for 30 minutes and again at 45 and 60 minutes. RESULTS: There was no correlation between age, weight, body mass index, vertebral column length, or time from delivery to placement of the block, and the spread of sensory block after subarachnoid injection of hyperbaric lidocaine. Only height weakly correlated with the spread of block (r2 = 0.15). CONCLUSIONS: While height may have some small influence on the spread of sensory block, the variation in spread of block within patients of the same height is large. The data suggest that adjusting the dose of local anesthetic injected based on differences in patient height would provide no clinically significant benefit.

Complications of labor analgesia: epidural versus combined spinal epidural techniques.

Both epidural and combined spinal epidural (CSE) analgesia can provide maternal pain relief during labor. Currently, there are few data comparing the risks and complications of these two techniques. We recorded the incidence and severity of anesthetic-related complications in 1022 laboring parturients. Ninety-eight women opted for either no or parenteral analgesia, 388 chose epidural, and 536 requested CSE analgesia. Women choosing CSE analgesia most often received an intrathecal injection of sufentanil 10 micrograms at the time of epidural catheter insertion. The epidural catheters were then dosed as needed as the intrathecal analgesia waned. Women who received CSE analgesia were more likely to itch (41.4% vs 1.3%) or complain of nausea (2.4% vs 1.0%) or vomiting (3.2% vs 1.0%) than those receiving solely epidural analgesia. Patients who requested only epidural analgesia were more likely to suffer an unintended dural puncture (4.2% vs 1.7%). Fewer than 10% developed hypotension with either technique. The risk of headache was the same with both anesthetics (4%-10%) and did not differ from the incidence of headache in women not receiving neuraxial analgesia (10%-14%). Six patients required epidural blood patch for moderate to severe postural headache. Four of these women suffered a dural puncture with the 18-gauge Hustead epidural needle. The other two women had reportedly uncomplicated epidural and CSE analgesia. These data suggest either neuraxial analgesic technique can safely relieve the pain of labor. CSE analgesia is a safe alternative to epidural analgesia for labor and delivery.

Intrathecal sufentanil labor analgesia: the effects of adding morphine or epinephrine.

Intrathecal opioids can provide labor analgesia. We attempted to prolong the duration of intrathecal sufentanil analgesia by adding epinephrine or morphine. Forty-one healthy, term nulliparae with cervical dilation < 5 cm participated in this double-blind, randomized protocol. Using a combined spinal and epidural technique, we gave intrathecal injections of either sufentanil 10 micrograms, sufentanil 10 micrograms plus epinephrine 200 micrograms, or sufentanil 10 micrograms plus morphine 250 micrograms. At baseline and every 5 min for 30 min thereafter, we recorded arterial blood pressure and asked the patients to rate their pain, nausea, and pruritus on visual analog scales. The women continued to rate these variables every 30 min until they requested additional analgesia. They then received 10 mL of 0.25% bupivacaine via the epidural catheter, and rated the above variables every 30 min until they requested additional epidural drug injection. Both morphine and epinephrine prolonged the duration of sufentanil analgesia. Only morphine prolonged analgesia after the first dose of epidural bupivacaine. However, because women in the morphine group experienced significantly more side effects throughout the study period, we do not recommend intrathecal morphine for labor analgesia.

Comparison among intrathecal fentanyl, meperidine, and sufentanil for labor analgesia.

This study compared the analgesic efficacy of intermittent injections of intrathecal fentanyl (10 micrograms), meperidine (10 mg), or sufentanil (5 micrograms) administered to 65 parturients during the first stage of labor. The groups did not differ in onset or duration of effective analgesia. The meperidine group, however, had significantly lower pain scores once cervical dilation progressed beyond 6 cm. Side effects included mild pruritus and nausea. After intrathecal drug injection, variable decelerations of the fetal heart rate increased in the fentanyl and meperidine groups. All neonates had a 5-min Apgar score of 7 or more. We conclude that intermittent intrathecal injections of fentanyl, meperidine, or sufentanil can provide adequate first-stage labor analgesia. Meperidine appears to provide more reliable analgesia as the first stage of labor progresses.