The use of remifentanil for Cesarean section in a parturient with recurrent aortic coarctation.

PURPOSE: To illustrate the clinical utility of a short acting opioid (remifentanil) based general anesthetic for Cesarean section in a parturient with compromised cardiac function. CLINICAL FEATURES: A 23-yr-old primigravida, complicated by a recurrent aortic coarctation with an approximate 50% narrowing of the aortic arch, presented for elective Cesarean section at 37 wk gestational age. Initially asymptomatic, her clinical condition had deteriorated as the pregnancy progressed, with worsening episodes of mild chest pain and shortness of breath. A semi-elective Cesarean section under general anesthesia was planned at 37 wk to minimize the potential for aortic complications associated with the hemodynamic stress of labour. Remifentanil was infused at 0.05 to 0.1 microg x kg(-1) x min(-1) with good sedation and analgesia for the placement of invasive monitors. The infusion was increased to 0.2 microg x kg(-1) x min(-1) for induction, and combined with isoflurane 0.4 to 0.6% for maintenance of anesthesia. The patient maintained stable hemodynamics throughout and her trachea was extubated without difficulty at the end of the procedure. The newborn did not require tracheal intubation, mask ventilation or naloxone and was in excellent condition upon transfer to the well baby nursery. CONCLUSION: Remifentanil, when used as part of an opioid-based general anesthetic for Cesarean section, can provide maternal hemodynamic stability with minimal neonatal respiratory depression and should allow for immediate postoperative tracheal extubation of the mother.

Intrathecal fentanyl is superior to intravenous ondansetron for the prevention of perioperative nausea during cesarean delivery with spinal anesthesia.

This study compares intrathecal (IT) fentanyl with IV ondansetron for preventing intraoperative nausea and vomiting during cesarean deliveries performed with spinal anesthesia. Thirty healthy parturients presenting for elective cesarean delivery with standardized bupivacaine spinal anesthesia were randomized to receive 20 microg IT fentanyl (Group F) or 4 mg IV ondansetron (Group O) by using double-blinded methodology. At eight specific intervals during the surgery, a blinded observer questioned the patient about nausea (1 = nausea, 0 = no nausea), observed for the presence of retching or vomiting (1 = vomiting or retching, 0 = no vomiting or retching), and recorded a verbal pain score (0-10, 0 = no pain, 10 = worst pain imaginable). Cumulative nausea, vomiting, and pain scores were calculated as the sum of the eight measurements. Intraoperative nausea was decreased in the IT fentanyl group compared with the IV ondansetron group: the median (interquartile range) difference in nausea scores was 1 (1, 2), P = 0.03. The incidence of vomiting and treatment for vomiting was not different (P = 0.7). The IT fentanyl group had a lower cumulative perioperative pain score than the IV ondansetron group; the median difference in the cumulative pain score was 12 (8, 16) (P = 0.0007). The IT fentanyl group required less supplementary intraoperative analgesia. The median difference in the cumulative fentanyl dose was 100 (75, 100) microg fentanyl, (P = 0.0002).