The relationship of preoperative anxiety with failure of extension of epidural analgesia for cesarean section

BACKGROUND: Patients anesthetized by extension of epidural analgesia during labor frequently experience intraoperative visceral pain during cesarean section. Visceral pain is known to be related to anxiety. We evaluated pain and preoperative anxiety using the numeric rating scale (NRS-11), and examined the relationship of anxiety with failure of extension of epidural analgesia due to intraoperative pain. METHODS: Patients received continuous epidural infusion at a rate of 10 ml/h for labor pain. Two percent lidocaine mixed with 100 microg fentanyl, 1:200,000 epinephrine, and 2 mEq bicarbonate was injected through the epidural catheter for cesarean section. Failure of epidural anesthesia was defined as the need for conversion to general anesthesia or supplementation with opioids, sedatives, or inhalants after epidural anesthesia for cesarean section. We investigated the relationship of preoperative factors including preoperative anxiety with failure of epidural anesthesia. RESULTS: Heavier weight of parturients, more cervical dilatation at the time of epidural analgesia administration, higher pain NRS score after epidural analgesia, higher pain NRS score before epidural analgesia for cesarean section, and lower rate of iv pethidine due to shivering were associated with a higher failure rate of epidural anesthesia. The failure rate of epidural anesthesia was comparable between the high anxiety group (NRS > 4) and the low anxiety group (NRS < or = 4). CONCLUSIONS: Preoperative anxiety evaluated by NRS may not be associated with failure of extension of epidural analgesia due to visceral pain during intrapartum cesarean section.

Effectiveness of spinal anesthesia after epidural labor analgesia versus spinal anesthesia only for intrapartum cesarean section

BACKGROUND: Spinal anesthesia (SA) after epidural labor analgesia (ELA) can have advantages over augmentation of ELA due to its rapid onset and high-quality analgesia. However, unexpected side effects and diverse failure rates have been reported in women that received SA after ELA. We prospectively compared the effectiveness and side effects of SA after ELA versus SA only for intrapartum cesarean section. METHODS: The ELA/SA group received continuous epidural infusion at a rate of 10 ml/h for labor pain. In both groups, spinal anesthesia was induced with 10 mg of 0.5% hyperbaric bupivacaine and 15 microg of fentanyl using a pencil point needle. The rate of conversion to general anesthesia, the need for intraoperative analgesic supplements, and the incidence of high spinal block and hypotension were investigated. RESULTS: The rate of conversion to general anesthesia was higher in the ELA/SA group compared with the SA group (15.2 vs. 2.7%). Eighty percent of the conversion cases in the ELA/SA group were converted due to lack of sensory block. The need for intraoperative analgesic supplements and the rates of high spinal block and hypotension were comparable in the two groups. CONCLUSIONS: SA after ELA is associated with a high rate of conversion to general anesthesia during intrapartum cesarean section.

The effects on Apgar scores and neonatal outcomes of switching from a combination of phenylephrine and ephedrine to phenylephrine alone as a prophylactic vasopressor during spinal anesthesia for cesarean section / 대한마취과학회지

BACKGROUND: Ephedrine, unlike phenylephrine, has a dose-related propensity to depress fetal pH during spinal anesthesia during cesarean section. A low arterial umbilical cord pH has a strong association with neonatal mortality and morbidity. The purpose of this retrospective study was to investigate influences of vasopressor change on Apgar scores and adverse neonatal outcomes in cesarean section. METHODS: In obstetric anesthesia, we changed the prophylactic vasopressor from a combination of phenylephrine and ephedrine to phenylephrine alone in 2000. We evaluated the impact of vasopressor change on Apgar scores (1 and 5 min), incidence of Apgar score < 7 (1 and 5 min), neonatal seizure, continuous positive airway pressure (CPAP), intermittent positive pressure ventilation (IPPV), intraventricular hemorrhage (IVH), periventricular leucomalacia (PVL), and hypoxic ischemic encephalopathy (HIE) in low-risk elective cesarean sections during a period when the combination of phenylephrine and ephedrine was used (2008-2009, two years) and the period of phenylephrine use alone (2011-2012, two years). RESULTS: There were no differences in Apgar scores (1 and 5 min), the incidence of 5 min Apgar score < 7, neonatal seizure, CPAP, IPPV, IVH, PVL, and HIE between the two time periods. However, the incidence of 1 min Apgar < 7 was decreased during the period of phenylephrine use compared with the period of phenylephrine and ephedrine use (P = 0.002). CONCLUSIONS: Conversion from a combination of phenylephrine and ephedrine to phenylephrine alone as a prophylactic anti-hypotensive drug during spinal anesthesia for cesarean section in low-risk pregnancy may be associated with a significant decrease in the incidence of 1 min Apgar < 7.