Effect of high-volume systematic local infiltration analgesia in Caesarean section: a randomised, placebo-controlled trial.

BACKGROUND: Pain after Caesarean section is often treated with opioids with a risk of side effects. Wound infiltration with local anaesthetics is effective and has few side effects, but volume vs. dose concentration has not been examined. METHODS: Ninety patients scheduled for elective Caesarean section included in a randomised, double-blinded, placebo-controlled trial receiving infiltration with 50 ml ropivacaine 0.5% or 125 ml ropivacaine 0.2% or 50 ml 0.9% saline (placebo) during surgery. Surgery was performed under lumbar spinal anaesthesia. Primary endpoint was post-operative pain. Secondary endpoints were rescue analgesic, post-operative nausea and vomiting, time spent in the postanesthesia care unit (PACU) and time to first mobilisation. RESULTS: No difference in pain response between groups, but time until maximum pain score was prolonged in the ropivacaine 0.5% group compared with the placebo group (P = 0.0493). The administration of ketobemidone at 24 h post-operatively in the ropivacaine 0.5% group was reduced compared with the placebo group (P = 0.020), and between the ropivacaine 0.2% group and the ropivacaine 0.5% group (P = 0.044). No significant differences between groups were found concerning time spent in the PACU, to first mobilisation or in number of women with nausea/vomiting (P ≥ 0.05). No complications related to ropivacaine were observed. CONCLUSIONS: Systematic infiltration with a high concentration, low volume compared with low concentration, high volume showed no significant effect on post-operative pain intensity. However, a statistically significant, but clinically limited opioid sparing effect was demonstrated compared with placebo in the high concentration, low volume group.

Per-operative cerebral near-infrared spectroscopy (NIRS) predicts maternal hypotension during elective caesarean delivery in spinal anaesthesia.

BACKGROUND: Spinal anaesthesia-induced maternal hypotension is common during elective caesarean section. This study evaluated whether cerebral near-infrared spectroscopy predicts maternal hypotension, defined as a 25% reduction in systolic blood pressure or heart rate or presentation of clinical symptoms. METHOD: Thirty-eight ASA I-II parturients scheduled for elective caesarean section with spinal anaesthesia were monitored by near-infrared spectroscopy for changes in cerebral oxygenation (ScO(2)) with the recordings blinded to the anaesthesiologist. RESULTS: There was a 5% decrease in ScO(2) (median 8%, interquartile range 5-11%) in all 22 patients who developed hypotension, whereas only 2 of 13 women who did not develop hypotension had a 5% decrease in ScO(2). Median time from a 5% decrease in ScO(2) to hypotension was 81 (interquartile range 30-281) s. The sensitivity of near-infrared spectroscopy to predict hypotension was 1.00, with a specificity 0.85 and a predictability of 0.91. CONCLUSION: The results demonstrate a relationship between ScO(2) and impending hypotension during low-dose spinal anaesthesia for elective caesarean section. We suggest that immediate measures are taken to stabilise blood pressure if the near-infrared spectroscopy determined cerebral oxygenation decreases by more than 5%.

Occurrence of withdrawal in critically ill sedated children.

OBJECTIVES: To record the number of children with withdrawal symptoms after the administration of sedatives for mechanical ventilation, and to discuss the possible connection with the administration of midazolam. DESIGN: Retrospective data collection from case records and charts. SETTING: Medical and surgical intensive care unit (ICU) in a university hospital. PATIENTS: Children 6 months to 14 yrs of age who required sedation for mechanical ventilation (n = 40). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Kind and amount of sedatives and analgesics, duration of administration, and occurrence of withdrawal symptoms. The frequency of withdrawal symptoms was 35% (14/40) of the sedated children. A total dose of midazolam of >60 mg/kg was strongly significantly associated with occurrence of withdrawal. Statistical analysis to determine the occurrence of withdrawal associated with the administration of morphine was not possible. CONCLUSIONS: Signs and symptoms of a withdrawal reaction were observed in several children. The occurrence of withdrawal was statistically related to high doses of midazolam, but it was not possible to determine the influence of morphine. If large doses of midazolam and opioids have been administered, there may be justification for reducing the dose gradually instead of abruptly, or using longer-acting benzodiazepines or opioids on discontinuation of sedation.

Forced-air surface warming versus oesophageal heat exchanger in the prevention of peroperative hypothermia.

BACKGROUND: In a prospective, randomized, placebo-controlled study we investigated the efficacy of 2 different heating methods in 24 patients undergoing abdominal surgery of at least 2 h expected duration. METHODS: Group I: control, no active warming. Group II: forced-air surface warming on upper extremities and upper thorax. Group III: warming with oesophageal heat exchanger. All patients had a standardized, combined general and epidural anaesthesia. Core and skin temperatures were measured at induction of general anaesthesia, and subsequently every 30 min, and changes in total body temperature were calculated. RESULTS: There were no statistically significant differences between the 3 groups regarding demographic data. Patients in groups I and III developed hypothermia, while this was not the case with patients in group II. When using analysis of variance with repeated measurements, there was no significant difference in core temperature, comparing group I and group III (P = 0.299) or the interaction between time and treatment of these groups (P = 0.373). As a consequence, data from groups I and III were pooled and regarded as an internal group on the one hand, and group II as an external group on the other hand. Core temperature, the mean skin temperature and total body temperature were significantly different comparing the internal group and the external group. The interaction between time and treatment was likewise found to be significantly different. CONCLUSION: We conclude that in major abdominal procedures lasting 2 h or more, serious hypothermia develops unless effective measures to prevent hypothermia are used. Forced-air warming of the upper part of the body is effective in maintaining normothermia in these patients, while central heating with an oesophageal heat exchanger, at least in its present form, does not suffice to prevent hypothermia.

[Sedation of children on respirators. A questionnaire study on therapeutic strategies and withdrawal problems]. / Sedering af respiratorbehandlede børn. En spørgeskemaundersøgelse vedrørende behandlingsregimer og abstinensproblemer.

The purpose of this study was to identify the patterns of use of sedative agents and withdrawal problems in the paediatric intensive care unit (PICU). A questionnaire survey was mailed to 46 Danish intensive care units. Only 24 of these treated paediatric patients needing mechanical ventilation. The agents most frequently employed were morphine and midazolam. There was general satisfaction with the used drugs. The majority of departments noted that there was no protocol for sedation in their PICU. The majority of departments (70.8%) did not consider drug withdrawal to be a problem, but those departments who treated most children considered drug withdrawal to be a problem.

[Cutaneous symptoms after continuous subcutaneous injection of morphine]. / Hudsymptomer efter kontinuerlig subkutan morfinindgift.

We present two cases of patients who developed local swelling and induration after continuous subcutaneous infusion of morphine. Cutaneous complications of repeated subcutaneous injections of pentazocine, meperidine, ketobemidone and methadone are well described. There are few reports of similar reactions after subcutaneous administration of morphine. Both patients were later treated with sufentanil using the subcutaneous route without any reaction. Sufentanil might be an alternative to patients who cannot tolerate morphine.

Analgesic requirements for ESWL treatment. A double blind study.

This is a double blind study of the analgesic need during extracorporeal shock wave lithotripsy (ESWL) with a 2nd generation lithotriptor (Siemens Lithostar) in 56 patients. A control group of 28 patients received 2 ml saline intravenously and 28 patients received 2 ml (0.1 mg) fentanyl intravenously before the start of treatment. Before ESWL all patients had subcutaneous infiltration with 20 ml lidocaine 1% and suppository naproxen 500 mg. Pain scores according to a visual analog scale (VAS) were recorded after 600 and 1000 shock waves and at the end of treatment. The patients were comparable with regard to age, sex, weight, number of shock waves given and duration of treatment. Pain scores and the need for supplementary analgesics were not significantly different between the two groups. We conclude that routine use of morphine is unnecessary during extracorporeal shock wave lithotripsy with Siemens Lithostar.

[Prognosis in early and late ventricular fibrillation after acute myocardial infarction]. / Prognosen ved tidlig og sen ventrikelflimmer efter akut myokardieinfarkt.

Of 413 patients with in-hospital ventricular fibrillation complicating acute myocardial infarction 281 had early (less than 48 hours post infarction) ventricular fibrillation and 132 had late ventricular fibrillation. In-hospital and longterm prognoses were not influenced by time of ventricular fibrillation, but advanced age and signs of reduced left ventricular function were found to be independent significant risk factors for short and longterm prognoses.

Prognosis of late versus early ventricular fibrillation in acute myocardial infarction.

To determine the prognosis of late ventricular fibrillation (VF) after acute myocardial infarction (AMI), the length of the monitoring period after AMI was extended. All patients in this series were continuously monitored in a coronary care unit to ensure observation of all VF within 18 days of AMI. From 1977 to 1985, 4,269 patients were admitted with AMI and 413 (9.6%) had in-hospital VF. Of these 281 (6.8%) had early VF (less than 48 hours after AMI) and 132 (3.2%) had late VF (greater than or equal to 48 hours after AMI). In-hospital mortality was 50 and 54% for early and late VF, respectively (p = 0.31). Kaplan-Meier survival analysis showed better survival after discharge for patients with early versus late VF (p = 0.009) but this difference was fully explained by the presence of heart failure. Survival analysis showed the same prognosis after 1, 3 and 5 years for early and late VF, when VF was not associated with heart failure. When VF was associated with heart failure (secondary VF) early VF had a greater mortality than late VF after 2 and 5 years. Logistic regression analysis showed that heart failure (relative risk 1.9 [1.1 to 3.1]) and cardiogenic shock (relative risk 3.9 [1.8 to 8.5]) were significant risk factors for in-hospital death. Late VF compared to early VF had no prognostic implication (relative risk 1.0 [0.6 to 1.6]). For patients discharged from the hospital, risk factors were heart failure (1.8 [1.1 to 2.8]) and previous AMI (1.6 [1.3 to 2.1]).(ABSTRACT TRUNCATED AT 250 WORDS)