Epidural electrical stimulation test versus local anesthetic test dose for thoracic epidural catheter placement: a prospective observational study.

PURPOSE: This study examined the concordance between epidural electrical stimulation test (EEST) and local anesthetic (LA) test dose to indicate correct thoracic epidural catheter position. The relationship between the test results and epidural postoperative analgesia was also assessed. METHODS: This prospective observational cohort study was done in patients receiving thoracic epidural analgesia for abdominal surgery. After insertion, the epidural catheter was tested using a nerve stimulator to elicit a motor response. The LA test dose was then administered, and sensory block to ice and pinprick was assessed. The primary outcome was the presence/absence of motor response to EEST and sensory block to test dose. Concordance of responses was assessed using kappa statistics, and their predictive power of postoperative epidural analgesia was evaluated. RESULTS: Sixty-eight thoracic epidural catheters were inserted, of which 62 were used perioperatively. The kappa agreement between EEST and LA test dose responses was moderate at 0.42 (95% confidence interval [CI], 0.18 to 0.67). Positive responses to EEST and LA test dose were observed in 62 (100%) and 50 (81%) patients, respectively, while 52 patients (84%) showed adequate analgesia postoperatively. The sensitivity (95% CI) of EEST and LA test dose to predict adequate postoperative epidural analgesia was 1 (0.93 to 1) and 0.79 (0.65 to 0.89), respectively, and the positive predictive values (95% CI) of EEST and LA test dose were 0.84 (0.75 to 0.93) and 0.82 (0.71 to 0.92), respectively. CONCLUSION: Following thoracic epidural catheter insertion, the responses to the EEST and LA test dose showed "moderate" agreement. The EEST has a higher sensitivity than the LA test dose to predict adequate epidural analgesia following abdominal surgery, however, both tests have a comparable positive predictive value.

RéSUMé: OBJECTIF: Cette étude a porté sur la concordance entre le test de stimulation électrique péridurale (EEST) et le test par une dose d'anesthésique local (AL) pour indiquer la position adéquate d'un cathéter thoracique. La relation entre les résultats des tests et l'analgésie péridurale postopératoire a également été évaluée. MéTHODES: Cette étude de cohorte observationnelle prospective a été menée chez des patients recevant une analgésie péridurale thoracique pour chirurgie abdominale. Après insertion, le cathéter épidural a été testé au moyen d'un stimulateur nerveux pour déclencher une réponse motrice. La dose test d'AL a alors été administrée et le blocage sensitif à la glace et aux piqûres a été évalué. Le critère d'évaluation principal était la présence ou l'absence de réponse motrice à l'EEST et au blocage sensitif à la dose test. La concordance des réponses a été évaluée au moyen de statistiques kappa et leur prédiction de l'efficacité de l'analgésie péridurale postopératoire a été évaluée. RéSULTATS: Soixante-huit cathéters périduraux thoraciques ont été insérés parmi lesquels 62 ont été utilisés en périopératoire. La concordance kappa entre les réponses à l'EEST et à la dose test d'AL a été modérée : 0,42 (intervalle de confiance [IC] à 95 %, 0,18 à 0,67). Les réponses positives à l'EEST et à la dose test d'AL ont été observées chez respectivement 62 (100 %) et 50 (81 %) patients, tandis que 52 patients (84 %) ont présenté une analgésie postopératoire adéquate. La sensibilité (IC à 95 %) de l'EEST et de la dose test d'AL pour la prédiction de l'analgésie péridurale postopératoire a été, respectivement, de 1 (0,93 à 1) et 0,79 (0,65 à 0,89) et les valeurs prédictives positives (IC à 95 %) de l'EEST et de la dose test d'AL ont été, respectivement, de 0,84 (0,75 à 0,93) et 0,82 (0,71 à 0,92). CONCLUSION: Après insertion d'un cathéter péridural thoracique, la concordance entre l'EEST et la dose test d'AL s'est avérée « modérée ¼. La sensibilité de l'EEST pour la prédiction d'une analgésie péridurale adéquate après chirurgie abdominale est supérieure à celle de la dose test d'AL; toutefois les deux tests ont des valeurs prédictives positives comparables.

Anesthetic management during labor and delivery: a 21-year review of women with cancer in a tertiary care center.

STUDY OBJECTIVE: To describe the anesthetic management of labor and delivery in patients presenting with cancer during pregnancy at one institution. DESIGN: Retrospective data collection of pregnant cancer patients who delivered between January 1988 and December 2009. SETTING: University-affiliated teaching hospital. MEASUREMENTS: Clinical data on cancer diagnosis and treatment and obstetric, neonatal, and anesthetic management of the study patients were compiled. Analysis was done based on whether the cancer was diagnosed before or during pregnancy. MAIN RESULTS: The incidence of cancer during pregnancy at our institution was 0.1%. No difference was noted in the incidence of cancer diagnosed before and during pregnancy was noted. Women with a cancer diagnosis during pregnancy had more clinical symptoms, a higher rate of inductions (37% vs 11%; P = 0.0002) and premature deliveries (48% vs 20%; P = 0.0003) than those with a cancer diagnosis before delivery. No differences between groups in neonatal outcome were noted. Most patients received regional anesthesia for labor and delivery (75%); a significant number (22%) also received general anesthesia for cesarean section. Life-threatening complications were seen in those with mediastinal tumors or metastases. CONCLUSION: Women with cancer diagnosed during pregnancy are likely to require prompt therapeutic intervention and have a potential for premature delivery. Anesthetic management should be tailored to the individual type of cancer, depending on the severity of symptoms, stage of cancer, and associated systemic involvement.

Patient-controlled analgesia with fentanyl provides effective analgesia for second trimester labour: a randomized controlled study.

PURPOSE: To examine dose and lockout intervals for effective fentanyl patient-controlled analgesia (PCA) in second trimester genetic termination of pregnancy, and compare three different fentanyl PCA regimes with morphine PCA. METHODS: In a double-blind randomized study, 60 ASA physical status I-II patients received one of three fentanyl PCAs or morphine PCA. Labour was induced with prostaglandins and PCA use continued until delivery. Within two hours following delivery, four visual analogue scales (VAS) were administered measuring anticipated pain, pain relief in labour and delivery, and overall satisfaction. The drug delivery/demand ratio for two hours preceding delivery was obtained from the PCA pump. The outcome variables were analyzed using the Chi square test and analysis of variance as appropriate. RESULTS: The delivery/demand ratio was 0.71 +/- 0.27 (mean +/- standard deviation) for morphine; 0.67 +/- 0.21 for fentanyl 50 micro g, lockout six-minute; 0.63 +/- 0.21 for fentanyl 25 micro g, lockout three-minute; and 0.81 +/- 0.17 for fentanyl 50 micro g, lockout three-minute groups. We found no significant differences among the four groups with respect to using delivery/demand ratio as a measure of pain relief. Morphine had the highest rate of side effects compared to fentanyl. There was strong evidence of differences among groups with regard to patient satisfaction and expected pain, and moderate evidence of differences in the delivery and labour pain scores. CONCLUSION: This study found PCA fentanyl 50 micro g with a lockout period of six minutes provided satisfactory analgesia for second trimester labour.