Epidural Neostigmine versus Fentanyl to Decrease Bupivacaine Use in Patient-controlled Epidural Analgesia during Labor: A Randomized, Double-blind, Controlled Study.

BACKGROUND: The addition of opioids to epidural local anesthetic reduces local anesthetic consumption by 20% but at the expense of side effects and time spent for regulatory compliance paperwork. Epidural neostigmine also reduces local anesthetic use. The authors hypothesized that epidural bupivacaine with neostigmine would decrease total hourly bupivacaine use compared with epidural bupivacaine with fentanyl for patient-controlled epidural analgesia. METHODS: A total of 215 American Society of Anesthesiologists physical status II, laboring parturients requesting labor epidural analgesia consented to the study and were randomized to receive 0.125% bupivacaine with the addition of either fentanyl (2 µg/ml) or neostigmine (2, 4, or 8 µg/ml). The primary outcome was total hourly local anesthetic consumption, defined as total patient-controlled epidural analgesia use and top-ups (expressed as milliliters of 0.125% bupivacaine) divided by the infusion duration. A priori analysis determined a group size of 35 was needed to have 80% power at α = 0.05 to detect a 20% difference in the primary outcome. RESULTS: Of 215 subjects consented, 151 patients were evaluable. Demographics, maternal and fetal outcomes, and labor characteristics were similar among groups. Total hourly local anesthetic consumption did not differ among groups (P = 0.55). The total median hourly bupivacaine consumption in the fentanyl group was 16.0 ml/h compared with 15.3, 14.6, and 16.2 ml/h in the 2, 4, and 8 µg/ml neostigmine groups, respectively (P = 0.55). CONCLUSIONS: The data do not support any difference in bupivacaine requirements for labor patient-controlled epidural analgesia whether patients receive epidural bupivacaine with 2 to 8 µg/ml neostigmine or epidural bupivacaine with 2 µg/ml fentanyl.

Association between cervical and thoracic somatic dysfunction among second-year osteopathic medical students.

CONTEXT: The ubiquitous nature of cervical and thoracic somatic dysfunction requires osteopathic physicians to have a strong working knowledge of regional spinal mechanics and their functional and dysfunctional interrelationships. OBJECTIVE: To determine whether cervical and thoracic somatic dysfunction occur concomitantly, particularly somatic dysfunction of the occipitoatlantal (OA) and upper thoracic (T1-T4) region of the spine. METHODS: A retrospective analysis of cervical and thoracic somatic dysfunction prevalence diagnosed by faculty in second-year osteopathic medical students was conducted. Somatic dysfunction was defined as a vertebral unit possessing any of the following palpatory characteristics: tissue texture changes, asymmetry of motion and relative position, restriction of motion, or tenderness (ie, TART criteria). For each instance of somatic dysfunction diagnosed, the segmental level identifying the superior segment of the involved vertebral unit was recorded, as well as the spinal region (ie, cervical [OA, atlantoaxial (AA), and C2-C7] or thoracic [T1-T12]). Descriptive analyses, a Pearson χ(2) test, and a regression model using an analysis of variance were performed on the data. RESULTS: Among 338 students included in the study, the following 5 vertebral segments were found to have the highest prevalence of somatic dysfunction: OA (257 [76.0%]), C3 (257 [76.0%]), T3 (247 [73.1%]), T5 (226 [66.9%]), and T4 (223 [66.0%]). A Pearson χ(2) test of association between the OA vertebral segment and the following segments were found to be statistically significant: AA (P=.024), C2 (P=.032), and T4 (P=.045). An analysis of variance revealed statistical significance between the prevalence of upper cervical (OA, AA, C2) somatic dysfunction and the prevalence of upper thoracic (P<.001) and midthoracic (T5-T8) (P<.001) somatic dysfunction; the prevalence of lower cervical (C3-C7) (P=.74) and lower thoracic (T9-T12) (P=.085) somatic dysfunction was not found to be significant. CONCLUSION: A statistically significant association between cervical somatic dysfunction and thoracic somatic dysfunction was confirmed. In addition, there was a statistically significant association between dysfunction of the OA and the AA, C2, and T4 vertebral segments. These results suggest that the number of dysfunctional vertebral segments in the upper thoracic and midthoracic spinal regions is directly proportional to the number of dysfunctional segments found in the upper cervical spinal region.

Blood pressure, but not cerebrospinal fluid fentanyl concentration, predicts duration of labor analgesia from spinal fentanyl.

BACKGROUND: There is a wide variability in dilution of drugs in cerebrospinal fluid after spinal injection, as measured near the site of injection. With local anesthetics, there is a wide variability in speed of onset, which correlates with block duration. The authors tested whether local cerebrospinal fluid drug concentrations and onset time would predict duration of analgesia from spinal fentanyl in laboring women. METHODS: After written informed consent, fentanyl (50 microg) was injected using the combined spinal epidural method in 56 women requesting analgesia for labor. The stylet was reinserted in the spinal needle, and 60 s later, the cerebrospinal fluid was aspirated for fentanyl assay. Time to analgesia and duration of analgesia were recorded, and data were analyzed by linear regression. RESULTS: Fifty-two women were included for data analysis. The cerebrospinal fluid fentanyl concentrations were 3.1 +/- 5.9 microg/ml, with a 7-fold range (0.9-5.9 microg/ml). Fentanyl concentration did not correlate with onset, initial sensory level at 5 and 10 min, or duration of analgesia. Decreased diastolic and increased systolic blood pressure and lower parity, but not fentanyl concentrations, correlated with longer labor analgesia. The resultant model was predictive when applied to data from four previous studies of spinal opioid analgesia duration. CONCLUSIONS: Contrary to our hypothesis, the local concentration of fentanyl in the cerebrospinal fluid 1 min after injection was not correlated with onset or duration of labor analgesia. The unexpected but consistent relationship between blood pressure and combined spinal epidural analgesia duration suggests that resting hemodynamic state affects the distribution and/or clearance of intrathecally administered opioids.

The effect of an alternative medical procedure upon low-frequency oscillations in cutaneous blood flow velocity.

OBJECTIVE: Compression of the fourth ventricle (CV-4) is a manual, noninvasive procedure that reportedly affects the cranial rhythmic impulse, a phenomenon recognized by practitioners of cranial manipulation, that is concomitant with low-frequency Traube-Hering (TH) oscillations in blood flow velocity. This study examines the CV-4 and its effect upon blood flow velocity. METHODS: Human subjects were paired with 28 individual physicians for application of the CV-4, and the duration of the application was recorded. Flowmetry records tracking the course of the procedure were obtained, 20 of which were useable for intergroup comparisons. Segments of these records (control, treatment, response) were Fourier-transformed; the Fourier-transformed spectra were subtracted from one another and the resultant difference-spectra compared. RESULTS: The mean CV-4 procedure length was 4.43 +/- 2.22 minutes. The mean frequency of the TH waveform visible in the blood flowmetry record was 7.10 +/- 2.07 cpm. The CV-4 procedure specifically affected the low-frequency oscillations in blood flow velocity. After application, the amplitude of the TH, 0.10 Hz, frequency wave increased (relative area units: control minus treatment [0.08010 units) compared with control minus response [-0.03358 units]; P = .011). CONCLUSIONS: This study showed that CV-4 has an effect on the TH frequency component of blood flow velocity. The practitioners of cranial manipulation who participated in this study affected their subjects in a quantifiable manner with the application of the CV-4 procedure.

Recording the rate of the cranial rhythmic impulse.

The rate of the cranial rhythmic impulse can be obtained by both palpation and instrumentation. However, the literature has reported higher rates obtained by instrumentation compared with palpation. The cranial rhythmic impulse has been demonstrated to be synchronous with the Traube-Hering oscillation, measured in blood flow velocity. The current study demonstrates that physicians tend to palpate the cranial rhythmic impulse and Traube-Hering oscillation in a 1:2 ratio. This finding provides an explanation for the difference between palpated and instrumentally recorded rates for the cranial rhythmic impulse.

Palpatory diagnosis of plagiocephaly.

INTRODUCTION: The term plagiocephaly, from the Greek plagios (oblique) and kephalê (head), means distortion of the head, and refers clinically to cranial asymmetry. Cranial Osteopathy, since it was first proposed, has focussed upon the diagnosis and treatment of birth trauma and cranial asymmetries, and consequently specific therapy for plagiocephalic deformities has been described. Osteopathic manipulation also has been proposed as a treatment for torticollis, a condition associated with plagiocephaly. For these reasons, we decided to look at the mechanics of the occipital bone and the adjacent atlas and bones of the cranial base, in relation to functional plagiocephaly. METHODS: The records of 649 children seen in an osteopathic practice in Lyon, France, were reviewed retrospectively, in compliance with the legal requirements of the Commission Nationale de l'Informatique et des Libertés (CRIL) and the Helsinki accord, for gender, age at presentation, birth history, obstetrical data (breech presentation, vacuum extraction, forceps delivery or Caesarean section), presenting complaint, side of posterior plagiocephaly, side of frontal plagiocephaly, torticollis, motion pattern of the occipital bone upon the atlas, and motion pattern of the spheno-occipital synchondrosis. RESULTS: We found significant correlations between plagiocephaly (right/left) and primipara (P=0.024), use of forceps (P=0.055) and extractor suction (P=0.055). Correlations were also found between flattening of the occiput (right/left) and lateral strain of the spheno-occipital synchondrosis (P=0.002) and between plagiocephaly (right/left) and occipito-atlantal motion (P=0.000). CONCLUSION: We found a significant correlation between the lateral strain pattern of the spheno-occipital synchondrosis and plagiocephaly and between rotational dysfunction of the occiput upon the atlas and the side of posterior plagiocephaly. We suggest that thorough neonatal osteopathic examination can identify individuals predisposed to develop posterior plagiocephaly.

Intravenous butorphanol, meperidine, and their combination relieve pain and distress in women in labor.

BACKGROUND: Systemic opioids are commonly administered during labor, but their efficacy has been recently questioned. In addition, laboratory and clinical studies provide a strong rationale for combining mu- and kappa-opioid receptor agonists for analgesia. The authors therefore studied, using validated intensity and affective scales and definitions of effective pain relief, the efficacy of intravenous meperidine, butorphanol, and their combination for labor analgesia. METHODS: Healthy women with singleton term pregnancy requesting analgesia during active labor were studied. Women were randomly assigned to receive 50 mg meperidine, 1 mg butorphanol, or 25 mg meperidine plus 0.5 mg butorphanol (n = 15/group). Pain intensity was assessed using a 0-10 numerical rating scale, and affective magnitude was assessed using a ratiometric descriptive scale before drug administration and between the sixth and seventh uterine contractions after drug administration. RESULTS: All three treatments reduced pain intensity equally. Butorphanol alone did not reduce pain affective magnitude, whereas the other treatments did. There was a significant correlation between reduction in pain intensity and affective magnitude in all groups, with greater reductions in affective magnitude than intensity. Overall, 29% of women exhibited clinically meaningful pain relief, with no difference among groups. Groups did not differ in incidence of opioid-induced adverse effects. CONCLUSIONS: These doses of meperidine and butorphanol do reduce pain intensity and affective magnitude, although a minority of patients achieve meaningful pain relief as defined in multiple patient populations, including laboring women. Combination of these drugs did not improve their therapeutic benefit.

Osteopathic manipulative treatment of somatic dysfunction among patients in the family practice clinic setting: a retrospective analysis.

CONTEXT: Relatively little has been published about contemporary use of osteopathic manipulative treatment (OMT) in family practice. OBJECTIVE: To provide an "epidemiology" of somatic dysfunction, assessing prevalence and severity of somatic dysfunction encountered in the family practice setting, also characterizing physician use of OMT. DESIGN: Retrospective analysis of Outpatient Osteopathic SOAP Note Form data collected in 1998 and 1999 by 20 osteopathic medical trainee-investigators under the supervision of seven site-based osteopathic physicians. SETTING: Three university-based, osteopathic family practice clinics. RESULTS: The authors analyzed records for 1331 patient encounters and 424 adult patients. The mean (SD) age of patients was 56.9 years (16.2 years), and 71% were women. The median number of days between repeat encounters was 29 days. Somatic dysfunction was diagnosed in 418 (31%) patient encounters, affecting a total of 1199 anatomic regions (2.9+/-1.2 anatomic regions per patient). Investigators used OMT in 335 (25%) patient encounters to treat a total of 952 anatomic regions (2.8+/-1.2 anatomic regions per patient). For women, the odds ratio for receiving OMT was 1.4 (95% confidence interval [CI], 1.0-2.2); for patients using analgesics, anti-inflammatory agents, or muscle relaxants, the odds ratio was 2.2 (95% CI, 1.2-4.1). Immediately after OMT, investigators reported that patients' somatic dysfunction resolved or improved in a total of 747 (96%) anatomic regions and remained unchanged in 32 (4%) anatomic regions (P<.001). The authors used cluster analysis to classify anatomic regions by prevalence and severity of somatic dysfunction. CONCLUSION: Somatic dysfunction was diagnosed in almost one-third of patient encounters. In one-quarter of patient encounters, investigators used OMT.

The effect of cranial manipulation on the Traube-Hering-Mayer oscillation as measured by laser-Doppler flowmetry.

CONTEXT: A correlation has been established between the Traube-Hering-Mayer oscillation in blood-flow velocity, measured by laser-Doppler flowmetry, and the cranial rhythmic impulse. OBJECTIVE: To determine the effect of cranial manipulation on the Traube-Hering-Mayer oscillation. DESIGN: Of 23 participants, 13 received a sham treatment and 10 received cranial manipulation. SETTING: Osteopathic Manipulative Medicine Department, Midwestern University, Downers Grove, Ill. PARTICIPANTS: Healthy adult subjects of both sexes participated (N = 23). INTERVENTION: A laser-Dopper flowmetry probe was placed on the left earlobe of each subject to obtain a 5-min baseline blood-flow velocity record. Cranial manipulation, consisting of equilibration of the global cranial motion pattern and the craniocervical junction, was then applied for 10 to 20 min; the sham treatment was palpation only. MAIN OUTCOME MEASURE: Immediately following the procedures, a 5-min posttreatment laser-Doppler recording was acquired. For each cranial treatment subject, the 4 major components of the blood-flow velocity record, the thermal (Mayer) signal, the baro (Traube-Hering) signal, the respiratory signal, and the cardiac signal, were analyzed, and the pretreatment and posttreatment data were compared. RESULTS: The 10 participants who received cranial treatment showed a thermal signal power decrease from 47.79 dB to 38.49 dB (P < .001) and the baro signal increased from 47.40dB to 51.30 dB (P < .021), while the respiratory and cardiac signals did not change significantly (P > .05 for both). CONCLUSION: Cranial manipulation affects the blood-flow velocity oscillation in its low-frequency Traube-Hering-Mayer components. Because these low-frequency oscillations are mediated through parasympathetic and sympathetic activity, it is concluded that cranial manipulation affects the autonomic nervous system.

A comparison of intrathecal fentanyl and sufentanil for labor analgesia.

BACKGROUND: The use of intrathecal opioids for labor analgesia continues to gain popularity, but there are limited data to guide this use. Previously, the authors established the ED50 for 60 min of labor analgesia from intrathecal sufentanil using an up-down sequential allocation study design. The current study first establishes an ED50 for intrathecal fentanyl using this same study design to establish an intrathecal potency ratio for fentanyl and sufentanil and then uses this ratio to compare the efficacy, duration of analgesia, and side effects from comparable doses of intrathecal fentanyl and sufentanil. METHODS: Seventy-five healthy nulliparous women requesting labor analgesia were enrolled in this two-part study. In phase I, 20 women received varying doses of fentanyl to establish an ED50 for 60 min of labor analgesia. In phase II, 55 women were randomized to receive either 36 microg intrathecal fentanyl or 8 microg sufentanil (2 times the ED50s) via a combined spinal-epidural technique and by double-blinded design. Pain relief, side effects, block height, maternal hemodynamics, and fetal heart rate were assessed throughout the study. The duration of spinal analgesia was considered to be the time from injection of study drug to the time of the patient's first request for additional analgesia. RESULTS: The ED50 of intrathecal fentanyl for 60 min of labor analgesia was found to be 18.2 microg, and therefore, the potency ratio of intrathecal sufentanil to intrathecal fentanyl at the ED50 level is 4.4:1. The duration of spinal analgesia was significantly longer from 8 microg intrathecal sufentanil than from 36 microg intrathecal fentanyl (104 +/- 34 vs. 79 +/- 34 min, P = 0.009). Otherwise, patient demographics, maternal hemodynamics, duration of labor, mode of delivery, motor block, subjective leg weakness, pruritus, nausea, pinprick sensory levels, visual analog scale pain scores, fetal bradycardia, and Apgar scores were similar between groups. CONCLUSION: The relative potency of intrathecal sufentanil to fentanyl for labor analgesia is 4.4:1. When using intrathecal opioids alone for early labor analgesia, 8 microg sufentanil produces labor analgesia lasting approximately 25 min longer than from 36 microg fentanyl, without a statistically significant increase in side effects. However, when making a choice between fentanyl and sufentanil, one must consider other important factors, such as the higher cost of sufentanil and the greater risk of dosing error due to the higher potency of sufentanil compared with fentanyl.