Postpartum neurologic symptoms following single-shot spinal block for labour analgesia.

BACKGROUND: As part of a quality assurance program, we investigated the incidence of postpartum neurologic symptoms in multiparous parturients receiving spinal block for labour analgesia, now in routine use in our labour ward. METHODS: Two hundred and twenty-nine consecutive multiparous parturients presenting for vaginal delivery and requesting spinal analgesia were asked to participate in this prospective study. All parturients received our standard intrathecal analgesia (ITA): 2.5 mg bupivacaine (1 ml) + 25 microg fentanyl (0.5 ml) using a 27-gauge Quincke-type needle. The patients filled in a questionnaire on the first day after delivery and again upon discharge. Complaints typical of neurologic sequelae were noted and a neurologic examination was performed, if necessary. All patients with postdural puncture headache (PDPH) and transient neurologic symptoms (TNSs) were interviewed by telephone 2 weeks after discharge to determine the course of the symptoms. RESULTS: Two hundred and twelve parturients were included in the study. Eighteen (8.5%) parturients complained of PDPH, the severity of which was mild in eight (4%), moderate in seven (3%), and severe in three (1%) patients, respectively. Fifteen (7%) mothers were treated with analgesics or bedrest only. Three (1%) patients were given an epidural blood patch. The paramedian approach was associated with the development of PDPH (P = 0.04). Transient neurologic symptoms were experienced by nine (4.2%) mothers, lasting 1-3 days, mostly presenting as bilateral pain in the buttocks or thighs. One parturient suffered from paraesthesia of the left foot lasting for 3 days. Forty (19%) mothers complained of non-postural headache and 28 (13%) of new-onset back pain. Three mothers (1%) would not want to receive a further spinal block. CONCLUSION: Transient neurologic symptoms (TNSs) after spinal block occurred infrequently. The incidence of PDPH was higher than in the obstetric population in general and calls for re-evaluation of our spinal block methods. Despite the occurrence of neurologic sequelae, patient acceptability was high.

Single-shot spinal block for labour analgesia in multiparous parturients*.

BACKGROUND: Intrathecal analgesia (ITA) is effective in late, rapidly progressing labour. In 1998, our hospital implemented the use of single-shot spinal block for pain relief in multiparous parturients. As part of a quality assurance programme, we assessed the analgesic efficacy, obstetric and neonatal outcomes and maternal satisfaction after this form of analgesia now in routine use in our labour ward. METHODS: Two hundred and twenty-nine consecutive multiparous parturients presenting for vaginal delivery and requesting analgesia were asked to participate in this prospective study. All parturients received our standard ITA: 2.5 mg bupivacaine (1 ml) + 25 microg fentanyl (0.5 ml) inserted via the L2-3 or L3-4 interspace. Routine monitoring included maternal vital signs, uterine contraction and fetal heart rate tracing. Pain scores (visual analogue scale (VAS) 0-10), sensory levels, motor block, side-effects and maternal satisfaction were recorded. Satisfactory analgesia was defined as a decrease in pain scores to three or less within 20 min after injection. The number of parturients requesting additional analgesia and the duration of spinal block (time from injection until request for additional medication after satisfactory analgesia had worn off) were recorded. RESULTS: Two hundred and nine parturients were included in the study. Satisfactory analgesia was achieved in 153 (73%) parturients. Fifty-five (26%) women requested additional analgesia: 38 (18%) because of unsatisfactory analgesia and 17 (8%) because analgesia ended before delivery. The duration of spinal block was 101 +/- 34 min. Pruritus occurred in 64%, fetal bradycardia in 7% and hypotension in 2% of deliveries. Pain relief was rated excellent by 65%, moderate by 20% and inadequate by 14% of the parturients. One hundred and sixty-nine (81%) women stated that they would like to have spinal analgesia again for pain relief during delivery. CONCLUSION: The majority of multiparous parturients found ITA adequate for pain relief during delivery. However, modifications are required in terms of improved timing, reliability and duration of analgesia.

Significance of wood terpenoids in the resistance of Scots pine provenances against the old house borer, Hylotrupes bajulus, and brown-rot fungus, Coniophora puteana.

We tested how terpenoid (i.e., monoterpenes and resin acids) composition and concentration in wood affects resistance against wood-borers and decaying fungi. Scots pine (Pinus sylvestris) wood from nine provenances having variable terpenoid profiles was studied against the old house borer, Hylotrupes bajulus, and the decay fungus, Coniophora puteana. Provenances represented a 1200-km N-S transect from Estonia to northern Finland, but they were all cultivated for 7 years in the same nursery field, in central Finland. Mean relative growth rate (MRGR) of small H. hajulus larvae positively correlated with the total monoterpene concentration of wood, and feeding was associated with high proportion of levopimaric+palustric acid in wood. Provenance did not affect the MRGR of small or big larvae, but big larvae consumed more wood and produced more frass on the northern Ylitornio trees than on the southern Rakvere and Ruokolahti trees. Low beta-pinene and total monoterpene concentration and low beta: alpha-pinene ratio in wood were all associated with a high number of eggs. The most northern Muonio provenance was the most favored as an oviposition site, differing significantly from Saaremaa, Tenhola, and Suomussalmi. Wood from Saaremaa, Tenhola, Ruokolahti, and Suomussalmi provenance was most resistant against decay fungus, differing significantly from that of Kinnula provenance. However, decay resistance was not clearly associated with the concentrations of wood terpenoids. These results suggest that monoterpene composition of wood affects resistance against wood-boring Cerambycid beetles, but resistance against wood-decaying fungi is not as clearly associated with wood terpenoids.

Comparison of remifentanil versus ketamine for paediatric day case adenoidectomy.

Few studies exist of using remifentanil and intravenous ketamine for anaesthetic induction in paediatric day case anaesthesia. Therefore, we studied 75 unpremedicated ASA I-II children (age 1-7 years) who were randomly assigned in a double-blind fashion to receive either remifentanil (1 microgram/kg), ketamine (0.7 mg/kg) or placebo before the anaesthetic induction. Anaesthesia was induced with propofol and maintained with O2-N2O-sevoflurane. Induction characteristics, recovery times and the need for postoperative analgesia were evaluated. The required induction dose of propofol was lower in the groups receiving remifentanil and ketamine compared with the group receiving placebo. After tracheal intubation heart rate and blood pressure were better attenuated with remifentanil than with ketamine or placebo. In the recovery room children in the placebo group required more doses of oxycodone than the other two groups but this did not reach statistical significance. There were no differences between the groups in achieving predetermined recovery end-points, attaining full points on the Steward score or in the well being at home. In conclusion, remifentanil provides haemodynamically more stable induction of anaesthesia compared with ketamine or placebo. Ketamine with its' longer duration of action does not prolong recovery but does not have a clear opioid-sparing effect either in the immediate postoperative period.

Analgesic efficacy of rectal acetaminophen and ibuprofen alone or in combination for paediatric day-case adenoidectomy.

BACKGROUND: Acetaminophen and non-steroidal anti-inflammatory drugs have different mechanisms of action. We investigated if combining rectal acetaminophen with ibuprofen would provide better postoperative analgesia compared with either drug alone after adenoidectomy in children. METHODS: 160 children, aged 1-6 yr, undergoing day-case adenoidectomy, were randomized to receive either acetaminophen 40 mg kg(-1), ibuprofen 15 mg kg(-1), their combination, or placebo rectally immediately after anaesthetic induction. A standard anaesthetic method was used and all children received alfentanil 10 micro g kg(-1) i.v. during induction. Meperidine 5-10 mg i.v. was used for rescue analgesia for a pain score (Objective Pain Scale) over 3. Recovery times, sedation scores and the need for rescue analgesia and adverse events during the first 24 h after anaesthesia were recorded. Rescue analgesic at home was ibuprofen 10 mg kg(-1). RESULTS: Total meperidine requirements were significantly less in the groups receiving acetaminophen, ibuprofen, or their combination compared with the group receiving placebo indicating an opioid-sparing effect of 19-28% (P<0.05). Children given acetaminophen were more sedated than those given ibuprofen (P<0.05). Discharge criteria were fulfilled earlier in the ibuprofen group than in all the other groups (P<0.05). At home, less children (49%) needed rescue analgesia in the combination group compared with the other groups (74-77%) (P<0.02). CONCLUSIONS: We conclude that prophylactically administered rectal acetaminophen combined with ibuprofen does not improve analgesia after adenoidectomy in the immediate postoperative period compared with either drug alone but does decrease the need for analgesia at home. Ibuprofen results in lesser sedation and faster discharge than when acetaminophen is used.

Analgesic efficacy of tramadol 2 mg kg(-1) for paediatric day-case adenoidectomy.

We studied the analgesic efficacy of tramadol 2 mg kg(-1) for post-operative analgesia after day-case adenoidectomy in children aged 1-3 yr. Eighty children were allocated randomly to receive tramadol 2 mg kg(-1) i.v. or placebo immediately after induction of anaesthesia. Anaesthesia was induced with alfentanil 10 microg kg(-1) and propofol 4 mg kg(-1) followed by mivacurium 0.2 mg kg(-1) for tracheal intubation. Anaesthesia was continued with sevoflurane in nitrous oxide and oxygen. All children were given ibuprofen rectally at approximately 10 mg kg(-1) before the start of surgery. Post-operative pain and recovery assessments were performed by a nurse blinded to the analgesic treatment using the Aldrete recovery score, the pain/discomfort scale and measurement of recovery times. Rescue medication (pethidine in increments of 5 mg i.v.) was administered according to the pain scores. A post-operative questionnaire was used to evaluate the need for analgesia at home up to 24 h after operation. Rescue analgesic at home was rectal or oral ibuprofen 125 mg. Children in the tramadol group required fewer pethidine doses than those in the placebo group (P = 0.014). Forty-five per cent of children receiving tramadol did not require post-operative analgesia at all compared with 15% of children receiving placebo (P = 0.003). Recovery times and the incidence of adverse effects were similar in the two groups in the recovery room and at home. The requirement for rectal ibuprofen at home did not differ between groups.

Recovery characteristics of sevoflurane or halothane for day-case anaesthesia in children aged 1-3 years.

BACKGROUND: Our objective was to compare the recovery characteristics of sevoflurane and halothane for short day-case anaesthesia in a specifically limited age group of children 1-3 yr. METHODS: Eighty unpremedicated children undergoing day-case adenoidectomy were randomly assigned to receive inhalational induction with either sevoflurane 8% or halothane 5% and nitrous oxide in oxygen (70/30) via a face mask. Tracheal intubation was performed without a muscle relaxant. Anaesthesia was continued with the volatile anaesthetic, adjusted to maintain heart rate and blood pressure within +/-20% of initial values. Recovery was evaluated using a modified Aldrete score, a Pain/Discomfort scale and by measuring recovery end-points. A postoperative questionnaire was used to determine the well-being of the child at home until 24 h after discharge. RESULTS: Emergence and interaction occurred significantly earlier after sevoflurane than halothane but discharge times were similar. More children in the sevoflurane group achieved full Aldrete scores within the first 30 min after anaesthesia, although this group suffered more discomfort during the first 10 min. The amount of postoperative analgesic administered was higher and the first dose given earlier in the sevoflurane group. Postoperative vomiting was more common with halothane, but side-effects in the two groups were otherwise similar in the recovery room and at home. CONCLUSIONS: In children 1-3 yr, sevoflurane provided more rapid early recovery but not discharge after anaesthesia of <30-min duration. Apart from more vomiting with halothane and more discomfort during the first 10 min after awakening with sevoflurane, the quality of recovery was similar with the two anaesthestics.

Induction characteristics of thiopentone/suxamethonium, propofol/alfentanil or halothane alone in children aged 1-3 years.

The aim of this study was to compare the effect of three different induction techniques, with or without neuromuscular block, on tracheal intubation, haemodynamic responses and cardiac rhythm. Ninety children, aged 1-3 years, undergoing day-case adenoidectomy were randomly allocated to three groups: group TS received thiopentone 5 mg kg-1 and suxamethonium 1.5 mg kg-1, group H 5 Vol.% halothane and group PA alfentanil 10 micrograms kg-1 and propofol 3 mg kg-1 for induction of anaesthesia. No anti-cholinergics were used. Holter-monitoring of the heart rate and rhythm was started at least 15 min before induction of anaesthesia and continued until 3 min after intubation. Tracheal intubation was performed by an anaesthetist blinded to the induction method and judged as excellent, moderate or poor according to ease of laryngoscopy, position of vocal cords and incidence of coughing after intubation. Tracheal intubation was successful at the first attempt in all children in groups TS and H and but only in 80% in group PA (P = 0.001). Intubating conditions were excellent in 22 (73%), 22 (73%) and one (3%) of the patients in groups TS, H and PA, respectively (P = 0.001). Cardiac dysrhythmias (supraventricular extrasystole or junctional rhythm) occurred in two (7%) patients in groups PA and H each (NS). Bradycardia occurred in 0 (0%), four (14%) and six (21%) children in groups TS, H and PA, respectively (P = 0.007 PA vs. TS, P = 0.03 H vs. TS). In conclusion, induction of anaesthesia with propofol 3 mg kg-1 and alfentanil 10 micrograms kg-1 without neuromuscular block did not provide acceptable intubating conditions in children 1-3 years, although it preserved arterial pressure better than thiopentone/suxamethonium or halothane. Cardiac dysrhythmias were few regardless of the induction method.

Midazolam premedication delays recovery from propofol-induced sevoflurane anesthesia in children 1-3 yr.

PURPOSE: To study the effect of midazolam premedication on the recovery characteristics of sevoflurane anesthesia induced with propofol in pediatric outpatients. METHODS: Sixty children, one to three years, presenting for ambulatory adenoidectomy were randomly assigned , in a double-blind fashion, to receive either 0.5 mg x kg(-1) midazolam (Group M) or placebo (Group P) p.o. 30 min before anesthesia. Anesthesia was induced with 10 microg x kg(-1) atropine, 10 microg x kg(-1) alfentanil, and 3-4 mg x kg(-1) propofol i.v.. Tracheal intubation was facilitated with 0.2 mg x kg(-1) mivacurium. Anesthesia was maintained with nitrous oxide/oxygen (FiO2 0.3) and sevoflurane with controlled ventilation. Recovery characteristics were compared using the modified Aldrete scoring system, the Pain/Discomfort scale and measuring specific recovery end-points (emergence, full Aldrete score, discharge). A postoperative questionnaire was used to evaluate the children's well-being at home until 24 hr after discharge. RESULTS: Emergence from anesthesia (22 +/- 9 vs 16 +/- 6 min (mean +/- SD), P = 0.005) and achieving full Aldrete scores (30 +/- 11 vs 24 +/- 16 min, P = 0.006) were delayed in patients receiving midazolam. Children in the placebo group were given postoperative analgesia sooner than those in the midazolam group (18 +/- 11 vs 23 +/- 8 min, P = 0.009). More children premedicated with midazolam suffered from arousal distress (20% vs 3%, P = 0.04) and scored higher on the Pain/Discomfort scale (P = 0.004) at 20 min after arrival in the recovery room. Discharge was not affected by premedication and well-being at home was similar in the groups. CONCLUSIONS: Oral premedication with midazolam delays early recovery but not discharge after ambulatory sevoflurane anesthesia induced with propofol in children one to three years. Midazolam did not improve the quality of recovery.

Premedication with midazolam delays recovery after ambulatory sevoflurane anesthesia in children.

UNLABELLED: We studied the effect of oral premedication with midazolam on the recovery characteristics of sevoflurane anesthesia in small children. In a randomized, double-blinded study, 60 children (1-3 yr, ASA physical status I or II) undergoing ambulatory adenoidectomy received either midazolam 0.5 mg/kg (Group M) or placebo (Group P) PO approximately 30 min before the induction of anesthesia. All children received atropine 0.01 mg/kg IV and alfentanil 10 microg/kg IV before the induction of anesthesia with sevoflurane up to 8 vol% inspired concentration in N2O 67% in O2. Tracheal intubation was facilitated with mivacurium 0.2 mg/kg. Anesthesia was continued with sevoflurane adjusted to maintain hemodynamic stability. In the postanesthesia care unit, predetermined recovery end points (emergence, recovery, discharge) were recorded. A pain/ discomfort scale was used to determine the quality of recovery. A postoperative questionnaire was used to evaluate the well-being of the patient at home 24 h after surgery. Emergence (spontaneous eye opening), recovery (full points on the modified Aldrete scale), and discharge were achieved later in Group M than in Group P (15+/-6 vs. 11+/-3 min [P = 0.002], 25+/-17 vs. 16+/-6 min [P = 0.01], and 80+/-23 vs. 70+/-23 min [P = 0.03]). Side effects, postanesthetic excitement, and analgesic treatment did not differ significantly between groups. At home, more children in Group P (30%) experienced disturbed sleep during the night compared with those in Group M (4%) (P = 0.007). IMPLICATIONS: In this randomized, double-blinded, placebo-controlled study, premedication with midazolam 0.5 mg/kg PO delayed recovery in children 1-3 yr of age after brief (<30 min) sevoflurane anesthesia. Except for more peaceful sleep at home, premedication did not affect the quality of recovery.

Sevoflurane-maintained anesthesia induced with propofol or sevoflurane in small children: induction and recovery characteristics.

PURPOSE: To compare the induction and recovery characteristics of sevoflurane anesthesia induced with either propofol or sevoflurane in pediatric outpatients. METHODS: Fifty-two children, aged 1-3 yr, presenting for ambulatory adenoidectomy were randomly allocated to receive 3 mg.kg-1 propofol i.v. or sevoflurane 8% inspired concentration for induction of anesthesia. Tracheal intubation was facilitated with 0.2 mg.kg-1 mivacurium. Anesthesia was maintained with nitrous oxide/oxygen (FiO2 0.3) and sevoflurane approximately 3-5% inspired concentration with controlled ventilation. Intubation was assessed by an anesthetist blinded to the induction method. Recovery characteristics were compared using the modified Aldrete scoring system, the Pain/Discomfort scale and measuring specific recovery times. A postoperative questionnaire was used to evaluate the children's well-being at home. RESULTS: Intubating conditions were similar in both groups. Emergence from anesthesia occurred earlier with sevoflurane for induction than with propofol (11 +/- 4 vs 17 +/- 7 min (mean +/- SD), P = 0.0002). More children in the sevoflurane group achieved full points on the modified Aldrete scoring system during the first 20 min after anesthesia (P < 0.05). However, children in the sevoflurane group scored higher in the Pain/Discomfort scale at 10 min after anesthesia (P = 0.04) and were given postoperative analgesics earlier than children in the propofol group (13 +/- 5 min vs 18 +/- 11 min, P = 0.03). The time to meet discharge criteria and recovery at home were similar. CONCLUSIONS: Induction of sevoflurane anesthesia with propofol for day-case adenoidectomy results in longer, but more calm, early recovery but does not delay discharge or affect recovery at home.

Recovery after halothane anaesthesia induced with thiopental, propofol-alfentanil or halothane for day-case adenoidectomy in small children.

We studied recovery from halothane anaesthesia in 93 children, aged 1-3 yr, undergoing day-case adenoidectomy. Children were allocated randomly to receive thiopental 5 mg kg-1 (group TH), alfentanil 10 micrograms kg-1 and propofol 3 mg kg-1 (group PAH) or 5% halothane (group HH) for induction of anaesthesia. In group TH, tracheal intubation was facilitated with succinylcholine (suxamethonium) 1.5 mg kg-1. In groups PAH and HH, tracheal intubation was performed without neuromuscular block, and succinylcholine was used only if required. Anaesthesia was maintained with 1-3% halothane during spontaneous respiration. Times to achieving predetermined recovery end-points were recorded. Quality of recovery was assessed using a score of 1-9 (best to worst) for sedation, crying, restlessness and agitation. A postoperative questionnaire was used to determine the well-being of the child at home, 24 h after operation. Emergence from anaesthesia (response to non-painful stimuli) occurred earlier in group HH (mean 9 (SD 6) min) than in groups PAH (13 (6) min, P < 0.01) and TH (18 (14) min, P < 0.01). Sitting up, walking and home readiness were achieved earlier in groups PAH and HH than in group TH (P < 0.05 for each variable). Children in group TH were more sedated during the first 30 min after anaesthesia than those in the two other groups (P < 0.05) while emergence-related delirium was more common in group HH than in group TH (P < 0.01). Well-being at home was similar in all groups. We conclude that induction of halothane anaesthesia with propofol-alfentanil or halothane provided more rapid recovery and earlier discharge than that with thiopental.