Neonatal outcome and mode of delivery after epidural analgesia for labour with ropivacaine and bupivacaine: a prospective meta-analysis.

In this prospective meta-analysis, we have evaluated the effect of epidural analgesia with ropivacaine for pain in labour on neonatal outcome and mode of delivery compared with bupivacaine. In six randomized, double-blind studies, 403 labouring women, primigravidae and multiparae, received epidural analgesia with ropivacaine or bupivacaine 2.5 mg ml-1. The drugs were administered as intermittent boluses in four studies and by continuous infusion in two. Apgar scores, neurological and adaptive capacity scores (NACS), degree of motor block and mode of delivery were recorded. The studies were designed prospectively to fit meta-analysis of the pooled results. Results showed similar pain relief and consumption of the two drugs. In the vaginally delivered neonates, NACS scores were approximately equal for both groups at 2 h, but at 24 h there were fewer infants with NACS less than 35 in the ropivacaine compared with the bupivacaine group (2.8% vs 7.6%; P < 0.05). Spontaneous vaginal deliveries occurred more frequently overall with ropivacaine than with bupivacaine (58% vs 49%; P < 0.05) and instrumental deliveries (forceps and vacuum extraction) less frequently (27% vs 40%; P < 0.01), while the frequency of Caesarean section was similar between groups. The intensity of motor block was lower with ropivacaine. There were no significant differences in adverse events.

Continuous epidural ropivacaine 0.2% for analgesia after lower abdominal surgery.

The purpose of this study was to determine whether a lumbar epidural infusion of ropivacaine 0.2% would provide effective analgesia with an acceptably low incidence of motor blockade and side effects after lower abdominal surgery. After combined general and epidural anesthesia and surgery, 125 patients were randomly assigned to receive either saline or ropivacaine 0.2% at a rate of 6, 8, 10, 12, or 14 mL/h (Groups R6, R8, R10, R12, and R14, respectively) for 21 h. Supplemental analgesia, if required, was provided with intravenous patient-controlled analgesia with morphine. Data were collected at 4, 8, and 21 h, and included morphine consumption, pain scores at rest and with coughing, motor and sensory block, and adverse events. Cumulative morphine consumption was less in Groups R10, R12, and R14 compared with the saline group. At 4 h analgesia was better among patients receiving ropivacaine, but at 21 h pain scores were identical. Sensory blockade at 8 and 21 h was greater in the ropivacaine groups compared with the saline group. Approximately 30% of R8, R10, and R12 patients, and 63% of R14 patients had demonstrable motor block of the lower limbs at 21 hours. We conclude that lumbar epidural ropivacaine 0.2% reduces parenteral morphine requirements but has little effect on pain scores and may be associated with motor blockade.

Anaesthetic considerations in high-risk pregnancy.

The pathophysiology, and principles of obstetric and anaesthetic management, of two high-risk situations have been reviewed. Information sources related to two additional problems are provided. The encouraging decline witnessed in perinatal morbidity and mortality in recent years, stems from multidisciplinary team care in tertiary centres. The obstetric anaesthetist who understands the pathophysiology of high-risk pregnancy, and the principles which underlie patient management, becomes an irreplaceable member of such perinatal care teams.

Epidural morphine prophylaxis of postoperative pain: report of a double-blind multicentre study.

In a double-blind placebo-controlled trial, 154 subjects, having intraperitoneal surgery or Caesarean section, and 53 patients undergoing lower limb orthopaedic surgery, received epidural morphine, 5 mg in 10 ml 0.9 per cent NaCl, or placebo, 10 ml 0.9 per cent NaCl, intraoperatively to determine duration of action and efficacy in preventing postoperative pain. Epidural morphine gave significantly longer postoperative analgesia (greater than 11 h) than placebo (3-6 h) in both groups (p less than 0.05) and patients who received morphine required less postoperative analgesic. Obstetric subjects experienced longer pain relief (18.3 +/- 1.3 h) than patients undergoing non-obstetric intraperitoneal surgery (9.2 +/- 1.2 h) (p less than 0.001). Generally mild pruritus affected more than 40 per cent of those receiving morphine, but over 90 per cent of obstetric patients receiving morphine. Respiratory depression occurred in 2-7 per cent of subjects who received morphine; unpredictable in onset, it responded rapidly to naloxone. Epidural bupivacaine, if employed for the surgical procedure, appeared to prolong epidural morphine analgesia. We consider epidural morphine useful in preventing postoperative pain, but its use demands close observation of respiratory rate in a high density nursing area.

Three per cent 2-chloroprocaine for caesarean section: appraisal of a standardized dose technique.

We evaluated 2-chloroprocaine, three per cent, in 44 women having epidural anaesthesia for Caesarean section. All subjects received a minimum dose of 25 ml (750 mg) in increments designed to allow early recognition of accidental subarachnoid or intravascular injection. Further increments were given as needed to achieve a T5 sensory level or higher. We recorded pulse and blood pressure at two-minute intervals and used a simple pain scale to assess analgesia. Ninety-three per cent of subjects had acceptable analgesia. Seventeen mothers required more than 25 ml to attain a T5 level; subjects having a BMI (body mass index) equal to or greater than 35, or over 35 years of age, demonstrated more cephalad spread. Hypotension (MAP 80 per cent of control or less) occurred in 24, mothers (54 per cent), often transiently, but an infused fluid volume exceeding 30 ml X kg-1 at delivery significantly reduced post-delivery hypotension. Nausea and vomiting accompanied the hypotension in 12 mothers. No neonatal depression occurred. We conclude the incremental administration of chloroprocaine, as described, permits safe administration of the drug, with excellent analgesia in most parturients.

Sodium citrate premedication in elective caesarean section patients.

The pH and volume of gastric contents from thirty-three patients undergoing elective caesarean section with thiopentone, nitrous oxide, succinylcholine anaesthesia were examined. Twenty patients received Gelusil 30 ml by mouth and thirteen patients received 30 ml of a 0.15 molar solution of sodium citrate. Following tracheal intubation, gastric fluid was sampled through an 18 French Salem sump tube place orally. Mean pH following Gelusil was 4.54 +/- 2.45 (SD) and 2.29 +/- 1.77 following sodium citrate. This difference was statistically different (P less than 0.05). There was no difference in gastric volume between the two groups. Thirty five per cent of patients receiving Gelusil had a pH less than 2.5. This low pH was more likely to occur with prolonged intervals between drug administration and sampling. Significantly more patients receiving sodium citrate had a low pH (85 per cent) and this low pH was not related to the duration of interval between administration and sampling. This study demonstrates that 30 ml of 0.15 molar sodium citrate is not a satisfactory alternative to 30 ml of Gelusil for increasing gastric pH in the paturient when given sixty minutes before operation.

Influence of maternal oxygen administration on the term fetus before labor.

Thirty-two healthy pregnant women at term who were to undergo cesarean section following epidural anesthesia were randomly assigned to receive preoperatively, by face mask, room air or oxygen for more than 10 minutes. Patients were kept at a left lateral tilt position of 15 degrees and were unaware which gas was administered. Oxygenation significantly increased (p less than 0.05) maternal PO2 to 283 mm Hg (SD 67). The cord vein PO2 of the group receiving oxygen was 34 mm Hg (SD 6), significantly higher (p less than 0.01) than the value of 26 mm Hg (SD 7) in the group receiving room air. The cord artery PO2 of the oxygen group was also significantly higher (p less than 0.05) at 20 mm Hg (SD 6) versus 15 mm Hg (SD 6). No other cord gas values were significantly different. There was no significant difference in the cord vein-artery PO2 differential. There was no significant difference in the infants' hematocrits determined at 4 hours of age in the two groups. All infants were in excellent condition (1-minute Apgar score greater than or equal to 8).