Mepivacaine for spinal anesthesia in parturients undergoing elective cesarean delivery: maternal and neonatal plasma concentrations and neonatal outcome.

OBJECTIVE: Worldwide, long-acting bupivacaine is most commonly used for spinal anesthesia in parturients undergoing elective Cesarean delivery. However, advances in surgical technique and shorter duration of surgery make short-acting local anesthetic like mepivacaine appropriate, particularly if combined with opioids to enhance postoperative maternal pain relief. MATERIAL AND METHODS: We assessed the effect of 4% hyperbaric mepivacaine (60 mg) plus 10 microg fentanyl for spinal anesthesia in 11 parturients undergoing elective Cesarean delivery. Sensory, motor and analgesic block characteristics, neonatal outcome (Apgar scores, umbilical cord blood analysis, neurologic and adaptive capacity score) as well as fetal and maternal mepivacaine plasma concentrations at delivery were determined (HPLC/UV). RESULTS: Motor block (Induction-Bromage 0) duration lasted 113 +/- 20 min. Effective analgesia (VAS < or = 40) was 128 +/- 35 min. Maternal and fetal mepivacaine free plasma concentration were 0.18 +/- 0.05 microg/ml and 0.10 +/- 0.03 microg/ml, respectively. The fetal to maternal (UV/MV)-ratio for mepivacaine free plasma concentration was 0.56. Apgar scores, NACScores and the umbilical blood analysis showed no evidence of neonatal depression. CONCLUSIONS: Particularly with short duration of surgery (21 +/- 5 min) intrathecal mepivacaine combined with fentanyl offers a favorable clinical alternative in parturients undergoing elective Cesarean delivery.

Intraabdominal infections: classification, mortality, scoring and pathophysiology.

Studies on intraabdominal infections have been difficult to compare in the past due to a missing system of classification for peritonitis. According to a recently developed classification system, secondary peritonitis, including spontaneous acute peritonitis, postoperative peritonitis and posttraumatic peritonitis, is the most common complication of severe intraabdominal infections. In several studies the mortality rate of postoperative peritonitis was still between 60% and 79%. Scoring systems were developed, some of them with the idea to predict mortality in peritonitis. Although the APACHE II score cannot predict the outcome of peritonitis in an individual patient, it is a reliable, valid and objective system for risk stratification in intraabdominal infections. Local trauma or bacterial contamination is responsible for an acute phase reaction, which involves the release of certain cytokines such as TNF-alpha, interleukin-1 (IL-1) and interleukin-6 (IL-6). The IL-6 seems to play an important role in the mechanism of the acute phase reaction, acting on hepatocytes to release acute phase proteins (e.g. CRP). Preliminary results of investigations of IL-6 levels in peritonitis indicate a possible role for IL-6 as a predictor of the outcome of peritonitis.