Mortality rates for Finnish anaesthesiologists and paediatricians are lower than those for the general population.

BACKGROUND: Previous studies on mortality among anaesthesiologists in the Nordic countries have reported inconsistent results. In an effort to examine mortality patterns among Finnish anaesthesiologists, we compared anaesthesiologists and paediatricians with the general population. METHODS: The year of birth and mortality data for anaesthesiologists and paediatricians deceased during the period 1996-2014 were assembled from the membership files maintained by the Finnish Medical Association. Data for the general population and causes of death were obtained from the database of Statistics Finland. Standardized mortality ratios (SMR) for anaesthesiologists and paediatricians were calculated using the general population as a reference. RESULTS: During the follow-up period, there were 62 deaths among anaesthesiologists and and 95 among peadiatricians. Anaesthesiologists had a lower mean age at death (66.9 years) than did peadiatricians (76.2 years). Standardized mortality ratios for both the groups were well below 1.0. The rate of suicides for anaesthesiologists was more than three times higher than that for paediatricians and more than five times higher for that of the general population. DISCUSSION: We found no evidence of increased mortality for anaesthesiologists or paediatricians. The number of suicides among anaesthesiologists was higher than among paediatricians and the general population.

Fatal injuries in rural and urban areas in northern Finland: a 5-year retrospective study.

BACKGROUND: Finland has the fourth highest injury mortality rate in the European Union. To better understand the causes of the high injury rate, and prevent these fatal injuries, studies are needed. Therefore, we set out to complete an analysis of the epidemiology of fatal trauma, and any contributory role for alcohol, long suspected to promote fatal injuries. As a study area, we chose the four northernmost counties of Finland; their mix of remote rural areas and urban centres allowed us to correlate mortality rates with 'rurality'. METHODS: The Causes of Death Register was consulted to identify deaths from external causes over a 5-year time period. Data were retrieved from death certificates, autopsy reports and medical records. The municipalities studied were classified as either rural or urban. RESULTS: Of 2915 deaths categorized as occurring from external causes during our study period, 1959 were eligible for inclusion in our study. The annual crude mortality rate was 54 per 100,000 inhabitants; this rate was higher in rural vs. urban municipalities (65 vs. 45 per 100,000 inhabitants/year). Additionally, a greater number of pre-hospital deaths from accidental high-energy trauma occurred in rural areas (78 vs. 69%). 42% of all pre-hospital deaths occurred under the influence of alcohol. CONCLUSION: The crude mortality rate for fatal injuries was high overall as compared to other studies, and elevated in rural areas, where pre-hospital deaths were more common. Almost half of pre-hospital deaths occurred under the influence of alcohol.

Current use of nitrous oxide in public hospitals in Scandinavian countries.

BACKGROUND: The use of nitrous oxide in modern anaesthesia has been questioned. We surveyed changes in use of nitrous oxide in Scandinavia and its justifications during the last two decades. METHODS: All 191 departments of anaesthesia in the Scandinavian countries were requested by email to answer an electronic survey in SurveyMonkey. RESULTS: One hundred and twenty-five (64%) of the departments responded; four were excluded. The 121 departments provided 807.520 general anaesthetics annually. The usage of nitrous oxide was reported in 11.9% of cases, ranging from 0.6% in Denmark to 38.6% in Iceland while volatile anaesthetics were employed in 48.9%, lowest in Denmark (22.6%) and highest in Iceland (91.9%). Nitrous oxide was co-administered with volatile anaesthetics in 21.5% of general anaesthetics [2.4% (Denmark) -34.5% (Iceland)]. Use of nitrous oxide was unchanged in five departments (4%), decreasing in 75 (62%) and stopped in 41 (34%). Reasons for decreasing or stopping use of nitrous oxide were fairly uniform in the five countries, the most important being that other agents were 'better', whereas few put weight on its potential risk for increasing morbidity. Decision to stop using nitrous oxide was made by the departments except in four cases. Of 87 maternity wards, nitrous oxide was used in 72, whereas this was the case in 42 of 111 day-surgery units. CONCLUSION: The use of nitrous oxide has decreased in the Scandinavian countries, apparently because many now prefer other agents. Difference in practices between the five countries were unexpected and apparently not justified on anticipated evidence only.

Feasibility of a laryngeal tube for airway management during cardiac arrest by first responders.

Airway management is of major importance in prehospital emergency care. Bag-valve mask (BVM) ventilation and endotracheal intubation (ETI) have been shown to be difficult, especially when caregivers are inexperienced. Alternative methods have been studied, and supraglottic devices have been shown to provide reasonable ease of placement and effective ventilation in manikin studies and anaesthetised patients. First responders (FR) are employed by many emergency medical services (EMS) to shorten initiation of emergency care, and they are trained to provide basic CPR including BVM and use of automated external defibrillators (AED) in case of out-of-hospital cardiac arrest (OCHA). The aim of this research was to study the feasibility of manikin-trained FRs using a laryngeal tube (LT) as a primary airway method during cardiac arrest. We trained 300 FRs to use a LT during OHCA. The FRs used a LT in 64 OHCA cases. The LT was correctly placed on the first attempt in 46/64 cases (71.9%) and on the second attempt in 13/64 cases (20.3%). Insertion was reported as being easy in 55/64 cases (85.9%). Median insertion time was 23.1s, with a range of 3-240s. We found that after manikin training, the FRs inserted the LT and performed adequate ventilation with a reasonable success rate and insertion time.

Timing of intravenous patient-controlled remifentanil bolus during early labour.

BACKGROUND: Remifentanil labour analgesia is superior to nitrous oxide but less potent than epidural analgesia. The short onset and offset times of effect suggest that the timing of the bolus in the contraction cycle could have importance. We hypothesised that administering a remifentanil bolus during contraction pause would improve analgesia in early labour. METHODS: With permission from the ethical committee and the National Authority of Medicines, 50 parturients with uncomplicated singleton pregnancies and informed consent participated in a double blind cross-over study. Intravenous doses of 0.4 µg/kg remifentanil with 1-min infusion times were used during two study periods lasting six to eight contractions. Remifentanil and saline syringes were attached to two patient-controlled devices, one of which administered the bolus immediately after a trigger and the other targeted to start 140 s before the next contraction. The parturients assessed contraction pain, pain relief, sedation and nausea. Oxygen saturation (SaO(2)) pulse and blood pressure were recorded. SaO(2)<95% was the indication for oxygen supplement. RESULTS: Forty-one parturients were included in the analyses. Because of the period effect, pain and pain relief scores were analysed separately for each of the study periods. The mean pain and pain relief scores were similar during the two different dosing regimens. Side effects, the need for supplemental oxygen, SaO(2) and haemodynamics were similar. In a subgroup with long and regular contractions, however, delayed boluses were associated with lower pain scores. CONCLUSIONS: Administering a remifentanil bolus during the uterine contraction pause does not improve pain relief.

Management of accidental dural puncture and post-dural puncture headache after labour: a Nordic survey.

BACKGROUND: a major risk with epidural analgesia is accidental dural puncture (ADP), which may result in post-dural puncture headache (PDPH). This survey was conducted to explore the incidence of ADP, the policy for management of PDPH and the educational practices in epidural analgesia during labour in the Nordic countries. METHODS: a postal questionnaire was sent to the anaesthesiologist responsible for Obstetric anaesthesia service in all maternity units (n=153) with questions relating to the year 2008. RESULTS: the overall response rate was 93%. About 32% (22-47%) of parturients received epidural analgesia for labour. There were databases for registering obstetric epidural complications in 13% of Danish, 24% of Norwegian and Swedish, 43% of Finnish and 100% of hospitals in Iceland. The estimated incidence of ADP was 1% (n approximately 900). Epidural blood patch (EBP) was performed in 86% (n≈780) of the parturients. The most common time interval from diagnosis to performing EBP was 24-48 h. The success rate for EBP was >75% in 67% (62-79%) of hospitals. The use of diagnostic CT/MRI before the first or the second EBP was exceptional. No major complication was reported. Teaching of epidurals was commonest (86%) in the non-obstetric population and 53% hospitals desired a formal training programme in obstetric analgesia. CONCLUSION: we found the incidence of ADP to be approximately 1%. EBP was the commonest method used for its management, and the success rate was high in most hospitals. Formal training in epidural analgesia was absent in most countries and trainees first performed it in the non-obstetric population.

Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine.

BACKGROUND: Central neuraxial blocks (CNBs) for surgery and analgesia are an important part of anaesthesia practice in the Nordic countries. More active thromboprophylaxis with potent antihaemostatic drugs has increased the risk of bleeding into the spinal canal. National guidelines for minimizing this risk in patients who benefit from such blocks vary in their recommendations for safe practice. METHODS: The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) appointed a task force of experts to establish a Nordic consensus on recommendations for best clinical practice in providing effective and safe CNBs in patients with an increased risk of bleeding. We performed a literature search and expert evaluation of evidence for (1) the possible benefits of CNBs on the outcome of anaesthesia and surgery, for (2) risks of spinal bleeding from hereditary and acquired bleeding disorders and antihaemostatic drugs used in surgical patients for thromboprophylaxis, for (3) risk evaluation in published case reports, and for (4) recommendations in published national guidelines. Proposals from the taskforce were available for feedback on the SSAI web-page during the summer of 2008. RESULTS: Neuraxial blocks can improve comfort and reduce morbidity (strong evidence) and mortality (moderate evidence) after surgical procedures. Haemostatic disorders, antihaemostatic drugs, anatomical abnormalities of the spine and spinal blood vessels, elderly patients, and renal and hepatic impairment are risk factors for spinal bleeding (strong evidence). Published national guidelines are mainly based on experts' opinions (weak evidence). The task force reached a consensus on Nordic guidelines, mainly based on our experts' opinions, but we acknowledge different practices in heparinization during vascular surgery and peri-operative administration of non-steroidal anti-inflammatory drugs during neuraxial blocks. CONCLUSIONS: Experts from the five Nordic countries offer consensus recommendations for safe clinical practice of neuraxial blocks and how to minimize the risks of serious complications from spinal bleeding. A brief version of the recommendations is available on http://www.ssai.info.

Anaesthesiological considerations on tocolytic and uterotonic therapy in obstetrics.

AIM: Significant side effects of tocolytic and uterotonic substances may be of concern to the anaesthesiologist. Recently, new drugs have been introduced having less side effects for both the mother and the neonate. METHODS: A literature search was undertaken mainly focusing on meta-analyses, to review the possible side effects that might affect the course of anaesthesia and to suggest which precautions should be considered to prevent the occurrence of significant interactions with anaesthetic manipulations and drugs. RESULTS: Magnesium sulphate has a proven benefit in lowering systolic blood pressure and preventing the occurrence of eclampsia, but not as a tocolytic. beta-adrenergic agonists are being abandoned due to the availability of tocolytic agents causing less side effects. Calcium channel blockers (CCB) are frequently used but can cause major maternal cardiovascular complications. Nitroglycerin seems to be appreciated as an acute tocolytic rather than a routine substance during pre-term labour. Cyclo-oxygenase-2 inhibitors are still under investigation but their tocolytic benefit is questionable mainly due to foetal side effects. Atosiban is considered the first-choice tocolytic. With respect to oxytocic drugs, oxytocine, prostaglandines and methylergometrine may all cause serious side effects especially when combined. The cardiovascular side effects of prostaglandins and methylergometrine can be life-threatening. Both oxytocin and carbetocin have a rather low risk for maternal complications. CONCLUSION: Atosiban and CCB are at least as effective tocolytic agents as beta-mimetics but have significantly less side effects. Magnesium sulphate can cause neuromuscular blockade, especially when combined with CCB. Concerning oxytocic agents, short-acting oxyctocin and long-acting carbetocin have the least side effects as compared with prostaglandins and methylergometrine.

Topographic electroencephalogram in children during mask induction of anaesthesia with sevoflurane.

BACKGROUND: Epileptiform patterns, spikes, polyspikes and periodic epileptiform discharges (PED) have been reported in electroencephalograms (EEGs) during anaesthesia induction with sevoflurane in healthy adults and children. Published recordings have been performed with a limited number of channels, and therefore the topographic distributions of these patterns are not known. METHODS: Twenty ASA I children aged 4-10 years undergoing routine operations were anaesthetized with 8% sevoflurane in 50%/50% oxygen and nitrous oxide using mask induction with controlled normoventilation. An EEG was recorded with a full 10-20 electrode system including orbitofrontal and ear electrodes, and a recording band of 0.016-70 Hz. Beat-to-beat heart rate (HR) was calculated off-line. RESULTS: Nineteen out of 20 children developed multifocal spikes and polyspikes with a maximum over the frontal lobes. Four patients developed suppression, which was almost continuous and lasted several minutes, and thereafter a continuous EEG resumed, a few spikes were seen and then a nonepileptiform pattern. In three children a couple of PED waves were seen at the onset of a continuous EEG. HR increased maximally before the onset of spikes. No motor phenomena were seen. CONCLUSION: These recordings confirm the epileptogenic property of sevoflurane in mask induction. The spikes and polyspikes had frontal multifocal maxima and may be missed in recordings from frontopolar electrodes used by depth-of-anaesthesia monitors. PED and burst suppression were synchronous over the whole cortex. Epileptiform activity was indiscernible from epileptiform waveforms without anaesthesia, such as the patterns seen in status epilepticus.

Significance of retrograde diastolic uterine artery blood flow during regional anesthesia in instrumented pregnant sheep.

BACKGROUND: We studied the interactions between uterine and placental hemodynamics during maternal hypotension in chronically instrumented fetal sheep. In addition, we investigated maternal hemodynamic characteristics, fetoplacental hemodynamics and fetal acid-base status when a retrograde diastolic uterine artery blood flow pattern is present during maternal hypotension. METHODS: Invasive maternal and fetal hemodynamic parameters, uterine (Q(UtA)) and placental (Q(UA)) volume blood flows and acid-base values were examined in 24 chronically instrumented sheep at baseline and during epidural-induced maternal hypotension at 117-132 (term 145) days of gestation. Uterine artery blood flow velocity waveforms were obtained by Doppler ultrasonography. RESULTS: Maternal hypotension decreased Q(UtA) without affecting Q(UA). During hypotension, eight out of 24 sheep demonstrated a retrograde diastolic blood flow velocity waveform pattern in the uterine artery. Maternal systolic, diastolic and mean arterial blood pressures were significantly lower in the retrograde group than in the antegrade group. No statistically significant differences in Q(UtA), Q(UA) and fetal blood gas values were detected between the two groups during hypotension. CONCLUSIONS: An acute decrease in uterine artery volume blood flow during maternal hypotension is not compensated by increased placental volume blood flow. A retrograde diastolic blood flow pattern in the uterine artery is related to lower maternal arterial pressures, especially during diastole. A uterine artery retrograde diastolic blood flow pattern does not have any additional detrimental short-term effects on fetal acid-base status.

Intravenous remifentanil vs. epidural levobupivacaine with fentanyl for pain relief in early labour: a randomised, controlled, double-blinded study.

BACKGROUND: We hypothesised that intravenous patient-controlled analgesia (IV PCA) with remifentanil could provide as satisfactory pain relief for labour as epidural analgesia. METHODS: Fifty-two parturients with singleton uncomplicated pregnancies were randomised to receive either IV PCA with remifentanil or epidural analgesia with 20 ml levobupivacaine 0.625 mg/ml and fentanyl 2 microg/ml in saline. The PCA dose of remifentanil was given over 1 min with a lockout time of 1 min. The dose was increased starting from the bolus of 0.1 microg/kg and following a dose escalation scheme up until the individual-effective dose was reached. The parturients assessed contraction pain (0-10), pain relief (0-4), sedation and nausea during 60 min. RESULTS: Forty-five parturients were included in the analysis. The median cervical opening was 4 cm before the study and 7 cm after the study. The median pain scores were 7.3 and 5.2 during remifentanil and epidural analgesia, respectively (P=0.009). The median pain relief scores were 2.5 and 2.8 (P=0.17). There was no difference between the groups in the proportion of parturients who discontinued due to ineffective analgesia, nor in the proportion of parturients who would have liked to continue the given medication at the end of the study. Sedation and low haemoglobin oxygen saturation were observed more often during remifentanil analgesia. Foetal heart rate tracing abnormalities were as common in both groups. CONCLUSIONS: In terms of pain scores, epidural analgesia is superior to that provided by IV remifentanil. However, there was no difference in the pain relief scores between the treatments.

Divergent effects of ephedrine and phenylephrine on cardiovascular hemodynamics of near-term fetal sheep exposed to hypoxemia and maternal hypotension.

BACKGROUND: We hypothesized that the administration of ephedrine and phenylephrine for maternal hypotension modifies cardiovascular hemodynamics in near-term sheep fetuses. METHODS: At 115-136 days of gestation, chronically instrumented, anesthetized ewes with either normal placental function or increased placental vascular resistance after placental embolization were randomized to receive boluses of ephedrine (n = 12) or phenylephrine (n = 12) for epidural-induced hypotension after a short period of hypoxemia. Fetal cardiovascular hemodynamics were assessed by Doppler ultrasonography at baseline, during hypotension and after vasopressor treatment. RESULTS: During hypotension, fetal PO(2) decreased and proximal branch pulmonary arterial and pulmonary venous vascular impedances increased. Additionally, in the embolized fetuses, the time-velocity integral ratio between the antegrade and retrograde blood flow components of the aortic isthmus decreased. These parameters were restored to baseline conditions by ephedrine but not by phenylephrine. With phenylephrine, weight-indexed left ventricular cardiac output and ejection force decreased in the non-embolized fetuses, and the proportion of isovolumetric contraction time of the total cardiac cycle was elevated in the embolized fetuses. CONCLUSIONS: After exposure to hypoxemia and maternal hypotension, ephedrine restored all fetal cardiovascular hemodynamic parameters to baseline. Phenylephrine did not reverse fetal pulmonary vasoconstriction or the relative decrease in the net forward flow through the aortic isthmus observed in fetuses with increased placental vascular resistance. Moreover, fetal left ventricular function was impaired during phenylephrine administration.

Charter on continuing medical education/continuing professional development approved by the UEMS Specialist Section and European Board of Anaesthesiology.

The mission of the Section and Board of Anaesthesiology of the European Union of Medical Specialists (EUMS/UEMS) is to harmonize training and medical practice in all European countries to continuously improve the quality of care. The need for continuous medical education in the field of anaesthesiology has long been recognized. However, specialty-based competencies are not the only requirements for successful medical practice. The need to acquire medical, managerial, ethical, social and personal communication skills on top of specialty-based competencies has developed into the principle of continuous professional development, which embraces both objectives. The Section and Board of Anaesthesiology of the EUMS/UEMS has approved a proposal of its Standing Committee on Continuous Medical Education/Continuous Professional Development to adopt the following charter on the subject.

Allocation of tasks between anesthesiologists and anesthesia nurses in Finland.

BACKGROUND: The shortage of anesthesiologists in Finland is worsening. A survey was carried out in 2003 among head anesthesiologists and head nurses to clarify current practice and the potentials for reorganizing tasks between anesthesiologists and anesthesia nurses. A national working group analyzed the results. METHODS: A questionnaire concerning doctor and nurse resources in anesthesiology, current allocation of tasks, and opinions on how these tasks could be reallocated was sent to 87 head anesthesiologists and 32 head nurses in 45 different hospitals. The answers from the doctors and nurses were compared. RESULTS: The response rate of doctors and nurses was 87% and 100%, respectively. In the enrolled hospitals there were 64 unoccupied positions for specialists in anesthesiology. The ratio of anesthesiologists to operation rooms (OR) they attended varied between 0.3 and 1.5. Doctors and nurses reported the allocation of tasks quite similarly. The great majority of respondents considered spinal, epidural, and interscalene brachial plexus blocks, and the induction of general anesthesia to be tasks that should be performed by an anesthesiologist. Very few respondents of either profession were willing to reallocate tasks so that nurses could deliver general anesthesia, including endotracheal intubation, even in low-risk patients. CONCLUSION: Nurses could be trained nationwide to perform procedures already performed by locally trained nurses in some hospitals. To cope with the shortage of anesthesiologists, other strategies must be adopted in addition to transferring part of their work load to nurses.

Ephedrine and phenylephrine for the treatment of maternal hypotension in a chronic sheep model of increased placental vascular resistance.

BACKGROUND: We hypothesized that ephedrine and phenylephrine are equal with respect to uterine and placental haemodynamics and fetal acid-base status after exposure to maternal hypoxaemia and hypotension in a chronic sheep model of increased placental vascular resistance (R(UA)). METHODS: At 114-135 days gestation, chronically instrumented fetal sheep underwent placental embolization leading to increased R(UA). Twenty-four hours after embolization, the ewes were anaesthetized and randomized to receive boluses of ephedrine (n=7) or phenylephrine (n=6) for epidural-induced hypotension after maternal hypoxaemia. Uterine (Q(UtA)) and placental (Q(UA)) volume blood flows and uterine vascular resistance (R(UtA)) and R(UA) were recorded. Uterine (PI(UtA)) and umbilical artery (PI(UA)) pulsatility indices were obtained by Doppler ultrasonography. Fetal arterial blood samples were analysed for acid-base values and lactate concentrations. RESULTS: During hypotension, Q(UtA), fetal pH, BE, and Po(2) decreased whereas R(UtA), PI(UtA), R(UA), and fetal lactate concentration increased. With ephedrine, Q(UtA), R(UtA), PI(UtA), R(UA), and fetal Po(2) returned to baseline. Fetal pH, BE, and lactate concentration did not change from hypotensive values. With phenylephrine, Q(UtA) remained lower (P=0.007) and R(UtA) (P=0.007), PI(UtA) (P=0.013), and R(UA) (P=0.050) higher than at baseline. Fetal Po(2) returned to baseline and fetal pH and BE did not change from hypotensive values. However, fetal lactate concentration increased further (mean difference 1.49, 95% confidence interval 0.72-2.26 mmol litre(-1); P=0.004). CONCLUSIONS: In a chronic sheep model of increased placental vascular resistance, compared with ephedrine administration, phenylephrine administration was associated with impaired uterine and placental haemodynamics and increased fetal lactate concentrations.

Comparison of remifentanil and nitrous oxide in labour analgesia.

BACKGROUND: We compared the efficacy and side-effects of remifentanil with those of nitrous oxide during the first stage of labour. METHODS: Twenty parturients participated in a randomized, double-blind, cross-over study. Intravenous remifentanil in 0.4 microg kg(-1) PCA doses with 1-min infusion and lock-out times and intermittent inhaled 50% nitrous oxide were compared during 20-min study periods with a 20-min wash-out sequence after each period. The parturients assessed the intensity of contraction pain (verbal numerical score 0-10), pain relief (score 0-4) and side-effects every 10 min. Noninvasive blood pressure, heart rate (HR), oxyhaemoglobin saturation (SaO2), end-tidal carbon dioxide, fractions of inhaled and exhaled oxygen and nitrous oxide and foetal heart rate (FHR) were recorded. Hypoxaemia and bradycardia were defined as SaO2<90% and HR<50, respectively. RESULTS: Fifteen parturients completed the study. There was no period effect or treatment-period interaction. The median decrease in pain score for remifentanil was 1.5 and that for nitrous oxide 0.5 (P=0.01). The parturients gave better pain relief scores with remifentanil than with nitrous oxide (median 2.5 vs. 0.5, respectively, P<0.001). Sedation was reported more often, and SaO2 was slightly lower during remifentanil administration. No episodes of hypoxaemia occurred. There was no difference in maternal blood pressure and HR or the incidence of abnormal FHR during remifentanil compared to nitrous oxide. Most parturients preferred remifentanil to nitrous oxide (14 vs. 1, P<0.001). CONCLUSIONS: This study suggests that IVPCA remifentanil provides better labour analgesia than intermittently inhaled nitrous oxide.

Pharmacokinetics of 0.5% levobupivacaine following ilioinguinal-iliohypogastric nerve blockade in children.

BACKGROUND: Bupivacaine (2 mg kg(-1)) has been recommended for blockade of the ilioinguinal and iliohypogastric nerves in paediatric patients undergoing inguinal surgery. We determined the plasma concentrations of levobupivacaine following ilioinguinal-iliohypogastric block. METHODS: Twenty children scheduled for elective surgery for inguinal surgery received 2 mg kg(-1) of 0.5% levobupivacaine. Surgical anaesthesia was maintained with mask inhalation of oxygen, nitrous oxide and sevoflurane. Venous blood samples were drawn at regular intervals up to 2 h and plasma was separated. Total venous plasma concentrations were determined by gas chromatography. Bupivacaine concentrations from a study with a similar protocol were used as historical controls for comparison. RESULTS: The groups were similar with respect to age, weight and dosage of local anaesthetic. The initial distribution half-time (Talpha), the peak plasma concentration (Cmax) achieved, the time to the peak plasma concentration were similar (Tmax), and the mean areas under the concentration time curve (AUC) were similar between the two local anaesthetics. CONCLUSIONS: Levobupivacaine and bupivacaine are equally absorbed to similar maximum concentrations.

Effects of ephedrine and phenylephrine on uterine and placental circulations and fetal outcome following fetal hypoxaemia and epidural-induced hypotension in a sheep model.

BACKGROUND: Recent studies support the use of alpha-agonists during regional anaesthesia in uncomplicated term pregnancies. We hypothesized that ephedrine and phenylephrine, administered for maternal hypotension following fetal hypoxaemia, are equal in respect of fetal outcome. METHODS: At 117-132 days gestation, chronically instrumented, anaesthetized and mechanically ventilated ewes were randomized to receive boluses of ephedrine (n=9) or phenylephrine (n=8) for maternal epidural-induced hypotension after a period of fetal hypoxaemia. Uterine (QUtA) and placental (QUA) volume blood flows were measured with perivascular transit-time ultrasonic flow probes, and uterine (RUtA) and placental (RUA) vascular resistances were computed from volume blood flows and maternal and fetal mean arterial pressures. Uterine (PIUtA) and umbilical artery (PIUA) pulsatility indices were obtained by Doppler ultrasonography. RESULTS: Ephedrine increased QUtA and decreased RUtA and PIUtA from a hypotensive to baseline level and had no significant effect on umbilical circulation. With phenylephrine, QUtA remained lower (P=0.011) and RUtA higher (P=0.043) than at baseline, although PIUtA decreased to baseline level. PIUA increased from baseline with phenylephrine (P=0.007), whereas QUA decreased (P=0.050). Maternal volume expansion with hydroxyethyl starch decreased RUtA significantly irrespective of the vasopressor used. There were no significant differences in fetal blood gas values or lactate concentrations between the ephedrine and phenylephrine groups. CONCLUSIONS: Despite the more favourable effects on uterine and placental circulations of ephedrine over phenylephrine, no significant differences in fetal acid-base status or lactate concentrations were observed.

Breast-feeding problems after epidural analgesia for labour: a retrospective cohort study of pain, obstetrical procedures and breast-feeding practices.

Various clinical practices have been found to be associated with breast-feeding problems. However, little is known about the effect of pain, obstetrical procedures and analgesia on breast-feeding behaviour. We designed a retrospective study with a questionnaire concerning pain, obstetrical procedures and breast-feeding practices mailed to 164 primiparae in Lapland. Altogether 99 mothers (60%) returned completed questionnaires that could be included in the analysis, which was carried out in two steps. Firstly, all accepted questionnaires were grouped according to the success or failure to breast-feed fully during the first 12 weeks of life. Secondly, an ad hoc cohort study was performed on the sub-sample of 64 mothers delivered vaginally. As many as 44% of the 99 mothers reported partial breast feeding or formula feeding during the first 12 weeks. Older age of the mother, use of epidural analgesia and the problem of "not having enough milk" were associated with the failure to breast-feed fully. Caesarean section, other methods of labour analgesia and other breast-feeding problems were not associated with partial breast feeding or formula feeding. In the sub-sample, 67% of the mothers who had laboured with epidural analgesia and 29% of the mothers who laboured without epidural analgesia reported partial breast feeding or formula feeding (P = 0.003). The problem of "not having enough milk" was more often reported by those who had had epidural analgesia. Further studies conducted prospectively are needed to establish whether a causal relationship exists between epidural analgesia and breast-feeding problems.

The effects of pre-emptive epidural sufentanil on human immune function.

BACKGROUND: Surgical stress and general anaesthesia suppress immune functions, including natural killer cell (NK) activity. This suppression could be attributed, at least in part, to the effect of opiates. METHODS: Twenty patients undergoing abdominal hysterectomy received epidural sufentanil (50 microg) either before (pre-emptive) or at the end (control group) of surgery. Post-operative pain relief was provided using sufentanil from a patient-controlled epidural analgesia (PCEA) system. Systemic immunity was assessed by determining leucocyte counts, NK cell counts and activity, lymphocyte response to mitogen stimulation, and secretion of pro-inflammatory cytokines. RESULTS: In the pre-emptive group there was a significant decrease in NK activity on the first and third post-operative day (P < 0.05) compared with baseline values and on the third postoperative day (P < 0.05) compared with the control group. The number of total leucocytes and neutrophiles increased in both groups post-operatively, but no differences were found in the levels of mononuclear lymphocyte populations or in their mitogen responses. Interleukin-6 (IL-6) concentration increased in both groups after the operation. In addition, at the end of the surgery the IL-6 level was greater in the control group than in the pre-emptive group. Interleukin-1 (IL-1) levels had decreased significantly at the end of surgery and 4 h later compared with baseline levels in the pre-emptive, but not in the control group. CONCLUSIONS: Pre-emptive epidural sufentanil during combined propofol and isoflurane anaesthesia had minor effects on the immune response after hysterectomy. The lower production of pro-inflammatory cytokines (IL-1, IL-6) in the pre-emptive group compared with the control group is beneficial, but its clinical importance remains to be determined.