Transdermal scopolamine patch in addition to ondansetron for postoperative nausea and vomiting prophylaxis in patients undergoing ambulatory cosmetic surgery.

STUDY OBJECTIVE: To determine the efficacy of transdermal scopolamine in addition to ondansetron in decreasing the incidence of postoperative nausea and vomiting (PONV). DESIGN: Randomized controlled trial. SETTING: Academic hospital. PATIENTS: 126 ASA physical status I and II patients undergoing outpatient plastic surgery with three or more risk factors for PONV. INTERVENTIONS: Patients were randomly assigned to one of two groups to receive (Group 1) a transdermal scopolamine (TDS) patch or (Group 2), a placebo patch two hours before surgery. MEASUREMENTS: Occurrence of vomiting, severity of nausea using a visual analog scale (VAS), rescue medication, pain intensity and pain medications, and side effects were recorded every hour until discharge from hospital, then every 4 hours thereafter for a total of 24 hours. MAIN RESULTS: A statistically significant reduction in postoperative nausea between 8 and 24 hours in patients receiving TDS was noted. CONCLUSIONS: Transdermal scopolamine in addition to ondansetron benefits patients at high risk for PONV undergoing outpatient plastic surgery for up to 20 hours after surgery.

Nitrous oxide anxiolysis for elective cesarean section.

STUDY OBJECTIVE: To determine if inhaled 40% nitrous oxide (N(2)O) via facemask is an effective anxiolytic in women undergoing elective cesarean section under spinal anesthesia. STUDY DESIGN: Prospective, randomized, double-blinded study. SETTING: Tertiary-care women's hospital. PATIENTS: Sixty American Society of Anesthesiologists physical status I and II patients scheduled for elective cesarean section under spinal anesthesia. INTERVENTIONS: Patients were randomized to 2 groups to receive either 100% O2 via facemask or 40% N2O in O2 via facemask. MEASUREMENTS: Vital signs (blood pressure, heart rate, and oxygen saturation) and measured variables (visual analog scale [VAS] anxiety, VAS pain, and sedation scores) were obtained at specific periods during the procedure (preoperatively, entering the operating room, spinal injection, skin incision, uterine incision, delivery, and at the conclusion of the surgical procedure). In addition, surgical time and delivery time, mean dose and percentage of patients requiring ephedrine or phenylephrine boluses, the emesis rate, and Apgar scores were measured. MAIN RESULTS: No differences were noted with respect to maternal mean blood pressure, heart rate, pulse-oximeter oxygen saturation, and sedation or VAS pain scores during the measured periods. No differences were noted in surgical and delivery times, mean dose, or percentage of patients who required ephedrine or phenylephrine to maintain maternal blood pressure, the emesis rate, or 1- and 5-minute Apgar scores. Mean anxiety scores for the N2O group were significantly lower at the time of spinal injection, skin incision, and uterine incision. Multivariate analysis of variance for high-anxiety patients (> or =50 VAS) revealed significantly lower VAS scores in the N2O group, compared with the O2 group again at spinal injection, skin incision, and uterine incision. CONCLUSIONS: Inhaled 40% N2O via facemask provides effective anxiolysis in women undergoing elective cesarean section under spinal anesthesia in patients with high anxiety (> or =50 VAS) at the time of spinal injection, skin incision, and uterine incision.

Induction of labor with oxytocin increases cesarean section rate as compared with oxytocin for augmentation of spontaneous labor in nulliparous parturients controlled for lumbar epidural analgesia.

STUDY OBJECTIVES: To study labor outcomes in parturients receiving oxytocin for augmentation or induction of labor, in the presence of labor epidural analgesia. DESIGN: Retrospective study of data from a continuous quality improvement database. SETTING: Tertiary-care hospital with more than 8000 deliveries per annum. MEASUREMENTS AND MAIN RESULTS: Of the 1671 healthy nulliparous women with singleton pregnancies and who requested labor epidural analgesia at our institution, 675 patients received oxytocin during elective induction of labor, whereas 996 patients received oxytocin for augmentation of spontaneous labor. Measured variables were cervical dilatation at time of epidural analgesia request, epidural insertion to 10-cm time, duration of stage 2 of labor, normal spontaneous vaginal delivery rate, cesarean section rate, operative vaginal delivery rate, and baby weight. Women admitted for induction of labor requested epidural analgesia sooner than those who had their labor augmented (p < 0.001). The incidence of cesarean section was higher in the induced group (p = 0.008). CONCLUSION: Patients who have their labor induced request analgesia sooner and are at a higher risk of cesarean section than are patients who go into labor spontaneously. Any study that purports to assess the effects of epidural analgesia in labor should distinguish between induced and augmented/spontaneous labor.

Piriformis syndrome in a patient after cesarean section under spinal anesthesia.

OBJECTIVES: The diagnosis, pathogenesis, and treatment of piriformis syndrome as a cause of persistent buttock and hip pain after spinal anesthesia are presented in this case report. CASE REPORT: A 29-year-old woman presented 5 days after cesarean delivery with sudden onset of pain in the left buttock and left hip radiating to the posterior knee with fever. She was subsequently diagnosed with piriformis syndrome. CONCLUSIONS: Back pain with radiation into the buttocks after spinal anesthesia is frequently attributed to the spinal procedure itself. However, prolonged sitting and weight bearing in the upright position after cesarean delivery can cause sciatic nerve compression at the sacroiliac joint with concomitant irritation, inflammation, and spasm of the piriformis muscle. Piriformis syndrome is frequently underdiagnosed in the obstetric population. Because the diagnosis of piriformis syndrome is based mainly on clinical signs and symptoms, the clinician must have a high index of suspicion.

Amniotic fluid embolism with second trimester pregnancy termination: a case report.

PURPOSE: Describe the diagnosis, clinical features, pathophysiology, treatment and anesthetic management of amniotic fluid embolism (AFE) in a patient undergoing second trimester pregnancy termination. CLINICAL FEATURES: A 30-yr-old gravida 2, para 1, woman was admitted for a dilatation and evacuation procedure for underlying intra-uterine fetal demise in her second trimester of pregnancy. Hypotension, shock, respiratory arrest, pulseless electrical activity, hemorrhage, disseminated intravascular coagulopathy, requiring cardiopulmonary resuscitation and blood transfusion complicated her intraoperative care. AFE was considered the most likely cause of this intraoperative event. CONCLUSIONS: It is now recognized that the pathophysiological features of AFE are similar to a type-1 hypersensitivity reaction ranging from mild systemic reaction to anaphylaxis and shock. AFE has a high maternal and fetal morbidity and mortality rate, requiring prompt recognition and treatment. In patients with cardiovascular instability, the treatment of AFE is similar to anaphylaxis requiring aggressive fluid hydration, cardiopulmonary resuscitation, administration of blood products and the use of vasopressors.

Thrombophilia, preeclampsia, and fetal demise: a case report.

A patient with thrombophilia, preeclampsia, and fetal demise who was taking low molecular weight heparin, was managed with epidural analgesia for labor and delivery of the fetus. The anesthetic considerations and medical concerns in such patients are discussed.

Accidental spinal analgesia in the presence of a lumboperitoneal shunt in an obese parturient receiving enoxaparin therapy.

IMPLICATIONS: A single shot spinal anesthetic is not practical in a patient with a lumboperitoneal shunt. Neuraxial block and a blood patch (if necessary) may be performed in a patient on enoxaparin therapy if current guidelines for managing patients on anticoagulant therapy are followed.