Pulmonary effects of bupivacaine, ropivacaine, and levobupivacaine in parturients undergoing spinal anaesthesia for elective caesarean delivery: a randomised controlled study.

BACKGROUND: Spinal anaesthesia is the method of choice for elective caesarean delivery, but has been reported to worsen dynamic pulmonary function when using bupivacaine. Similar investigations are lacking for ropivacaine and levobupivacaine. We have therefore compared the pulmonary effects of intrathecal bupivacaine, ropivacaine and levobupivacaine used for caesarean delivery. METHODS: Forced vital capacity, forced expiratory volume in the first second, and peak expiratory flow rate were measured in 48 parturients before and after onset of spinal anaesthesia using either 0.5% bupivacaine 10 mg, 1% ropivacaine 20 mg, or 0.5% levobupivacaine 10 mg. Apgar scores and umbilical arterial pH were recorded. RESULTS: The final level of sensory blockade was not different between groups. Forced vital capacity was significantly decreased with bupivacaine (3.6+/-0.5 L to 3.5+/-0.4 L, P<0.05) and ropivacaine (3.2+/-0.4 L to 3.1+/-0.5 L, P<0.05), but not with levobupivacaine (3.6+/-0.5 L to 3.4+/-0.6 L). Forced expiratory volume during the first second was not decreased in any group. Peak expiratory flow rate was significantly decreased with ropivacaine (5.5+/-1.5 L/s to 5.0+/-1.1 L/s, P<0.05) and levobupivacaine (from 6.0+/-1.1 L/s to 5.2+/-0.9 L/s, P<0.01). Neonatal vital parameters did not differ between the three groups. CONCLUSIONS: Decreases in maternal pulmonary function tests were similar following spinal anaesthesia with bupivacaine, ropivacaine, or levobupivacaine for caesarean delivery. The clinical maternal and neonatal effects of these alterations appeared negligible.

[Evaluation of a cadaver workshop for education in regional anesthesia]. / Bewertung eines Anatomieworkshops für die Regionalanästhesieausbildung.

BACKGROUND: The aim of the present investigation was to survey former participants (n=869) of a cadaver workshop using a mail questionnaire to assess the demographic data and the impact of these courses on daily practice. METHODS: The deadline for acceptance of return mail was 60 days. Descriptive statistics were employed for analysis of results. RESULTS: The response rate was 36.7% and the course was judged to be recommendable by 98.2%. The average course attendant was board certified and had spent a mean time of 9+/-6 years in anesthesiology. The highest quality and degree of subsequent practicability in daily routine was attributed to peripheral nerve block training on cadavers. Of the course participants two-thirds performed regional anesthesia procedures more often following attendance. The majority of course attendants had to defray at least a part of the course fee themselves, and one-third was required to invest leisure time to attend. CONCLUSION: Attendance of a cadaver workshop increased knowledge of clinical anatomy and enhanced performance of regional anesthesia procedures. Courses of this format constitute a currently underestimated adjunct to contemporary regional anesthesia education.

[Tumorectomy in conscious patient with suspected pregnancy associated breast cancer under cervical epidural anesthesia]. / Tumorektomie am wachen Patienten in zervikaler Epiduralanästhesie bei schwangerschaftsassoziiertem Mammakarzinom.

In this report we present a 35 year old pregnant woman (no significant disease in patient history, non smoker, primipara, gestational week 15) who had to undergo elective tumorectomy due to suspected pregnancy associated breast cancer. General anesthesia during pregnancy can potentially be harmful for the fetus (hypoxia, acidosis, premature delivery, teratogenicity). We decided to anesthetize the patient with a cervical segmental epidural block.

Accuracy in estimating the correct intervertebral space level during lumbar, thoracic and cervical epidural anaesthesia.

BACKGROUND: Even in the absence of factors concealing anatomical landmarks, high failure rates in correctly determining a given lumbar interspace have been reported. METHODS: Therefore, it was the aim of the present study to compare the assessed and factual level (determined by computed tomography) of epidural puncture in attending a regional anaesthesia cadaver workshop. Eighty-two anaesthetists performed 117 punctures. RESULTS: Vertebral interspaces between T8-L4 were correctly identified more often than those between C3-T5 (P < 0.05). Identification of an arbitrarily chosen vertebral interspace was excellent in both the cervical/high thoracic and thoracic/lumbar regions. CONCLUSION: As previously conjectured only for the lumbar region, we could confirm the tendency of anaesthetists to perform neuraxial puncture more cranially than expected also for the thoracic and cervical regions. The large majority of punctures (93.7%) was performed within one interspace of the predicted level.

A study of the paravertebral anatomy for ultrasound-guided posterior lumbar plexus block.

IMPLICATIONS: We investigated the feasibility of posterior paravertebral sonography as a basis for ultrasound-guided posterior lumbar plexus blockades. Posterior paravertebral sonography proved to be a reliable as well as accurate imaging procedure for visualization of the lumbar paravertebral region except the lumbar plexus.

Rectally administered dimenhydrinate reduces postoperative vomiting in children after strabismus surgery.

We have investigated the effectiveness of rectally administered dimenhydrinate on postoperative vomiting in children undergoing strabismus surgery, in a double-blind, randomized, placebo-controlled study. In one group, dimenhydrinate 50 mg was administered rectally 30 min before starting anaesthesia, whereas in the control group, placebo suppositories were given. Children who received dimenhydrinate showed a significantly (P < 0.001) lower incidence of vomiting (15%) than those in the control group (75%). We conclude that rectal administration of dimenhydrinate is an effective means of reducing postoperative vomiting in children undergoing strabismus surgery.

[Opioid therapy in Austria: results and analysis of a survey]. / Opioidtherapie bei Arzten für Allgemeinmedizin in Osterreich: Ergebnisse und Analyse einer Umfrage.

INTRODUCTION: Many causes are given as the main reason for inadequate pain therapy. The objective of our study was to demonstrate the current position of doctors in general practice all over Austria who prescribe prescriptions. METHODS: A total of 5,359 questionnaires were sent out to general practitioners in all federal states of Austria. These questionnaires contained 21 main questions on subjects relevant to pain therapy. RESULTS: On average, 16% of all general practitioners returned the questionnaires; 89.3% of these are acquainted with the WHO graduated scale, 87% have prescribed strong opioids. Old prejudices such as concerns about the side effects are hardly to be found now. Modern therapy strategies are used. CONCLUSION: Based on the data at hand, pain therapy for patients should be excellent. The reality, however, is somewhat different. The large number of doctors who did not reply makes it enormously difficult to make a statement about the position of pain therapy in Austria.

Extended duration of action of rocuronium in postpartum patients.

We studied the time course of action of a single bolus of 600 micrograms/kg rocuronium given during anesthesia with propofol, fentanyl, and nitrous oxide was studied in 12 nonpregnant and 12 postpartum patients. Neuromuscular effects were quantified by recording the indirectly evoked twitch response of the adductor pollicis muscle after ulnar nerve stimulation. In all patients, the trachea was intubated 60 s after administration of rocuronium. Onset time was similar in both groups (nonpregnant: 91 +/- 28 s vs. postpartum: 95 +/- 30 s), with the time to 25% twitch recovery being significantly longer (P < 0.001) in the postpartum patients (31.1 +/- 3.6 min) compared with the nonpregnant group (24.9 +/- 4.0 min). The time required for recovery from 25% to 75% of the control twitch response after reversal with neostigmine and atropine was significantly longer (P = 0.003) in postpartum (4.8 +/- 0.9 min) than in nonpregnant patients (3.2 +/- 0.6 min). These data suggest that pregnancy-induced changes result in prolonged effects of rocuronium in postpartum patients.

The onset of pipecuronium following application of the priming principle.

Pipecuronium bromide, a long acting non-depolarizing neuromuscular blocking agent was administered to four groups of 10 patients using the priming technique. The effects of the combination of two different priming doses (0.01 or 0.015 mg kg-1) given at two different time intervals (3 or 4 min) before the 'main' intubating dose (0.07 or 0.065 mg kg-1) were investigated. Onset times were recorded and the intubation conditions were scored and compared with a group of patients receiving the same total amount of pipecuronium (0.08 mg kg-1) in a single bolus injection. Intubating conditions at 90 s after administration of the intubating dose were found to be significantly improved in all primed groups but the onset times, evaluated using the response of the adductor pollicis muscle to a single twitch stimulation, were similar to that observed after the single bolus injection. The optimal priming combination is considered to be 0.01 mg kg-1 of pipecuronium followed 3 to 4 min later by 0.07 mg kg-1.

Rocuronium bromide: time-course of action in underweight, normal weight, overweight and obese patients.

The duration of action and recovery of 0.6 mg kg-1 rocuronium in underweight, normal weight, overweight and obese patients were investigated. Forty-eight patients were divided into four groups, according to their body mass index, and were given 0.6 mg kg-1 rocuronium. The onset time, the duration 25% and either the spontaneous or induced recovery were measured according to the random assignment. The onset time in the obese group was shorter 60 (50-90) s compared to the other groups (underweight: 95 (40-320) s, normal: 95 (50-200) s, overweight: 90 (50-260) s, but the difference did not reach the level of statistical significance. The duration 25% was slightly prolonged in the obese patients (31.5 (21.0-61.0) min) when compared to the underweight (25.0 (15.0-37.0) min), normal weight (26.0 (20.0-36.0) min) and overweight (27.0 (19.0-35.0) min) patients. No differences were observed in spontaneous (9.5-12.5 min) and induced (2.5-3.5 min) recovery.

The use of rocuronium (ORG 9426) in patients with chronic renal failure.

The pharmacodynamics of an initial dose of 0.6 mg.kg-1 rocuronium followed by three maintenance doses of 0.15 mg.kg-1 were studied during nitrous oxide/oxygen/isoflurane anaesthesia in patients with normal renal function (n = 12) and chronic renal failure (n = 12). The mean (SD) duration (min) of block after the initial dose was 28.0 (5.5) and 25.6 (11.7) respectively. The mean (SD) duration (min) of the effect of the three maintenance doses was 15.3 (4.0) and 14.2 (7.0); 17.3 (3.2) and 17.4 (8.7); 18.1 (2.8) and 19.1 (10.1) for the normal and renal failure patients respectively. The induced and spontaneous recovery indices were 3.7 (0.7) and 17.1 (6.9) in the normal group compared with 3.9 (0.5) and 19.0 (12.5) in the renal failure group and these values did not differ between the two groups. In this small study rocuronium appears to be suitable for patients with chronic renal failure. There is no evidence of prolonged block even when the drug is given in repeated doses for maintenance.

Evaluation of the time course of action of maintenance doses of rocuronium (ORG 9426) under halothane anaesthesia.

The time course of action of rocuronium was compared using three different sizes of maintenance doses after at least three subsequent administrations of the same repeat dose in each patients under halothane anaesthesia. Following endotracheal intubation facilitated with 0.6 mg.kg-1 rocuronium (ORG 9426), muscle relaxation was maintained in three groups each consisting of ten patients, using increments of equal repeat doses of either 75 micrograms.kg-1, 150 micrograms.kg-1 or 225 micrograms.kg-1 equivalent to 1/4, 1/2 and 3/4 of the ED95 of this new compound, respectively. Maintenance doses were administered when the twitch height depression induced by the previous dose returned to 25% of its control value. The clinical duration of the intubating dose averaged 27 +/- 7.5 min (mean +/- s.d.). The time course of action of the various maintenance doses depended on their size, but not on the number of administrations. The durations of repeat doses averaged 8-9 min, 14-16 min and 19-23 min after the low, medium and high maintenance doses, respectively. No overt cumulative effects were observed.

Evaluation of the endotracheal intubating conditions of rocuronium (ORG 9426) and succinylcholine in outpatient surgery.

The time-course of action and tracheal intubating conditions of rocuronium and succinylcholine under intravenous anesthesia with propofol, alfentanil, and nitrous oxide were studied in 30 patients undergoing outpatient surgery. The neuromuscular effects of both drugs were quantified by recording the indirectly evoked twitch response of the adductor pollicis muscle after ulnar nerve stimulation (0.1 Hz, 0.2 ms supramaximal stimuli). Patients were given either 0.6 mg/kg rocuronium (n = 20) or 1 mg/kg succinylcholine (n = 10) intravenously. Sixty seconds after the administration of the muscle relaxant, the trachea was intubated and the intubating conditions were scored by a "blinded" assessor. Intubating conditions were not different (P = 0.34) between the rocuronium and succinylcholine groups. The onset and duration of neuromuscular blockade were shorter with succinylcholine than with rocuronium. The depression of the twitch response to 5% of control value occurred in 0.8 +/- 0.1 min with 1 mg/kg succinylcholine and 1.2 +/- 0.5 min with 0.6 mg/kg rocuronium (P less than 0.01). The recovery of the twitch response to 25%, 75%, and 90% of its control value was shorter after succinylcholine (P less than 0.001) and occurred at 8.1 +/- 2.6, 10.3 +/- 3.9, 11.3 +/- 4.6 and 25.3 +/- 5.0, 33.1 +/- 5.9, 36.1 +/- 6.3 min after succinylcholine and rocuronium, respectively. Also the time required for spontaneous recovery from 25% to 75% of the control twitch response was significantly shorter (P less than 0.001) after succinylcholine (2.2 +/- 1.4 min) than after rocuronium (7.8 +/- 2.1 min). It is concluded that in spite of the pharmacodynamic differences between succinylcholine and rocuronium, the intubating conditions after administration of both compounds are similar and develop at the same rate.