Comparison of 2% lignocaine with adrenaline and fentanyl, 0.75% ropivacaine and 0.5% levobupivacaine for extension of epidural analgesia for urgent caesarean section after low dose epidural infusion during labour.

Low dose local anaesthetic and fentanyl epidural solutions are commonly 'topped-up' for urgent caesarean section. However, the block characteristics associated with newer local anaesthetics such as ropivacaine 0.75% and levobupivacaine 0.5% have not been fully determined. In a randomised double-blinded controlled clinical trial, we compared 2% lignocaine with adrenaline and fentanyl (LAF), 0.75% ropivacaine and 0.5% levobupivacaine for extension of low dose epidural analgesia for urgent caesarean section in 90 Asian parturients. There was no significant difference in the median, interquartile range, time to T4 loss of sensation to cold between LAF (9.5, 7.0 to 13.3 minutes), 0.75% ropivacaine (10.0, 7.0 to 15.0 minutes) and 0.5% levobupivacaine (10.0, 7.0 to 15.0 minutes). No woman required conversion to general anaesthesia. The supplementation rate did not differ between groups. Levobupivacaine provided a longer duration of sensory block compared to LAF but a similar duration to 0.75% ropivacaine. Under the conditions of this study there was no significant difference in time to surgical readiness (defined as loss of sensation to cold to T4) between LAF, 0.75% ropivacaine and 0.5% levobupivacaine groups. Ropivacaine and levobupivacaine are suitable alternatives for extending epidural analgesia for urgent caesarean section.

Comparison of the modified Airway Management Device with the Proseal laryngeal mask airway in patients undergoing gynaecological procedures.

BACKGROUND AND OBJECTIVE: The modified Airway Management Device (AMD) and the Proseal laryngeal mask airway (PLMA) are both supraglottic airway devices designed to maintain airway patency and allow ventilation during anaesthesia. In this prospective, randomized trial, we compared the two devices in patients undergoing major gynaecological procedures. METHODS: Eighty-two patients undergoing elective gynaecological surgery were randomized to two groups. Group A (n = 41) had the AMD and Group P (n = 41) the PLMA inserted after induction of anaesthesia. We compared the success of airway placement, time to achieve an airway, oropharyngeal leak pressure and complications associated during anaesthesia. RESULTS: There were no differences in patient characteristic profile for both groups. First time insertion success rates were significantly higher in Group P than in Group A (100% vs. 83%, P < 0.012). Time taken to achieve airway was also significantly shorter in Group P than in Group A (mean 21.9 +/- 7.8 s vs. 40.2 +/- 48.0 s, P < 0.001). The oropharyngeal leak pressure was significantly higher for Group P than Group A (mean 31.2 +/- 5.7 cmH(2)O vs. 24.2 +/- 8.3 cmH(2)O, P < 0.001). Ten patients in Group A had transient loss of airway during anaesthesia and needed manipulation of the airway device and four patients needed to have the airway switched to PLMA for the rest of the procedure. CONCLUSIONS: The modified AMD has a significant lower first time successful placement rate, required a longer insertion time and has a lower oropharyngeal leak pressure than the PLMA. It also demonstrated an increased loss of airway during anaesthesia. The modified AMD needs further evaluation on its efficacy and safety before its further use can be recommended.

Postoperative epidural hematoma or cerebrovascular accident? A dilemma in differential diagnosis.

An elderly lady developed an epidural hematoma following combined spinal-epidural anesthesia with a local anesthetic-opioid mixture for a vaginal hysterectomy. This occurred in association with the use of prophylactic subcutaneously administered unfractionated heparin. She had diabetes, hypertension and had previously undergone coronary artery bypass surgery and right carotid endarterectomy. Warfarin and aspirin were discontinued 2 weeks before the surgery. Postoperatively, an atypical presentation of backache, bilateral sensory loss and left lower limb monoplegia ensued. The initial clinical impression was of a cerebrovascular accident. Magnetic resonance imaging, however, revealed an extensive epidural hematoma that necessitated decompression laminectomy. Progression to paraparesis occurred but the patient gradually regained much of her functionality over the next 2 years.

Intravenous regional anaesthesia using lignocaine and tramadol.

INTRODUCTION: This prospective, randomised, double-blind study was designed to assess if the addition of 50 mg tramadol to 30 mL 0.5% lignocaine would improve the efficacy of intravenous regional anaesthesia. MATERIALS AND METHODS: Fifty-four adult patients undergoing upper limb surgery were randomly allocated to receive either 30 mL 0.5% lignocaine and 1 mL normal saline (group A) or 30 mL 0.5% lignocaine and 50 mg tramadol (group B). They were then assessed for onset of sensory and motor block and the VbAS score for tourniquet pain. RESULTS: Although more patients in group B had a faster onset of sensory and motor block, this was not significantly different. Patients in group B had a significantly lower VbAS score 30 min after tourniquet inflation and after change over to the distal tourniquet (P < 0.05). There were no complaints of postoperative nausea and vomiting. Two patients in group B developed localised skin urticaria of the forearm which resolved with the release of the tourniquet. CONCLUSION: There is a positive trend that tramadol might improve the quality of intravenous regional anaesthesia.