Obstetric anesthesia considerations in Kearns-Sayre syndrome: a case report.

Kearns-Sayre syndrome (KSS) is a rare mitochondrial myopathy that usually develops before 20 years of age. It demonstrates multisystemic involvement with a triad of cardinal features: progressive ophthalmoplegia, pigmentary retinopathy, and cardiac conduction abnormalities. In addition, patients might have cerebellar ataxia, a high content of protein in the cerebrospinal fluid, proximal myopathy, multiple endocrinopathies, and renal tubular acidosis. We herein report the successful obstetric analgesic and anesthetic management of a 28-year-old parturient patient with KSS who required labor analgesia and proceeded to deliver by cesarean section. We extrapolate that regional analgesia/anesthesia might be beneficial for reducing the metabolic demands associated with the stress and pain of labor in patients with KSS. Efficient postoperative analgesia should be provided to decrease oxygen requirements.

Small dose spinal bupivacaine for Cesarean delivery does not reduce hypotension but accelerates motor recovery.

BACKGROUND: Maternal hypotension occurs in 60-94% of Cesarean deliveries with 10-15 mg spinal bupivacaine. Reduced doses of bupivacaine may decrease the incidence of hypotension, nausea, and vasopressor use. The primary objective of this study was to compare 4.5 mg and 12 mg doses of intrathecal bupivacaine on maternal hemodynamics. The secondary objective was to determine if anticipated reductions in side effects were reflected in increased patient satisfaction. METHODS: Following Research Ethics Board approval and informed consent 52 term parturients undergoing elective Cesarean delivery were randomly assigned to isobaric bupivacaine 4.5 mg or hyperbaric bupivacaine 12 mg for spinal anesthesia. All patients received fentanyl 50 microg and morphine 200 microg intrathecally. Intravenous fluid and vasopressor administration were standardized. Maternal hemodynamics, and sensorimotor levels were recorded at regular intervals. Side effects and patient satisfaction were documented. RESULTS: Median cepahalad sensory block was C8 in both groups (NS) but the intensity of motor block was significantly less (P < 0.001) and of shorter duration (P < 0.001) with bupivacaine 4.5 mg. The proportion of patients requiring ephedrine (> 70%) and the quantities of ephedrine used were similar in both groups (NS). Use of supplemental analgesia, side effects, and measures of patient satisfaction were comparable in both groups. DISCUSSION: Intrathecal bupivacaine 4.5 and 12 mg yielded similar sensory block and side effects during Cesarean delivery. Patients receiving 4.5 mg did, however, experience significantly less motor blockade of shorter duration.

Evidence that intravenous vasopressors can affect rostral spread of spinal anesthesia in pregnancy.

BACKGROUND: The authors have previously observed an apparent association between rostral spread of spinal anesthesia and choice of intravenous vasopressor given to maintain maternal systolic arterial pressure during cesarean delivery. This study tested the hypothesis that an intravenous infusion of phenylephrine can reduce rostral spread of spinal anesthesia in pregnancy, compared with ephedrine. METHODS: The study was randomized and double blind. It compared phenylephrine 100 microg/ml (phenylephrine group, n = 30), and ephedrine 3 mg/ml (ephedrine group, n = 30), given by infusion, to prevent maternal hypotension during combined spinal-epidural anesthesia for cesarean delivery. Two ml intrathecal plain levobupivacaine, 0.5%, combined with 0.4 ml intrathecal fentanyl, 50 microg/ml, and 10 ml epidural saline was given with the patient in the sitting position. The upper level of neural blockade to cold and light touch sensation was recorded at 10 and 20 min postspinal. Epidural space pressure was recorded at 5, 10, 15, and 20 min. RESULTS: At 20 min, the upper dermatome blocked to cold sensation was median T3 (interquartile range, T2-T4) for the phenylephrine group, compared with T1 (T1-T2) for the ephedrine group (P = 0.001). At 20 min, the upper dermatome blocked to light touch sensation was median T5 (T4-T8) for the phenylephrine group, compared with T3 (T2-T6) for the ephedrine group (P = 0.009). The mean epidural space pressure in the phenylephrine group was 16 (13-19) mmHg, compared with 16 (13-18) mmHg in the ephedrine group (P = 0.63). CONCLUSIONS: This study provides evidence that intravenous phenylephrine can decrease rostral spread of spinal anesthesia in pregnancy, compared with intravenous ephedrine. Further work is required to investigate possible mechanisms and to assess its clinical significance.