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1. Epidural tramadol for postoperative pain after Cesarean section. Siddik-Sayyid S, Aouad-Maroun M, Sleiman D, Sfeir M, Baraka A. Department of Anesthesiology, American University of Beirut, Lebanu. Can J Anaesth 1999 Aug;46(8):731-5.
PURPOSE: To compare the post-operative analgesic effect of 100 mg vs 200 mg epidural tramadol and saline in patients undergoing elective Cesarean section.
METHODS: Sixty healthy women undergoing Cesarean delivery with epidural anesthesia were randomly allocated into three groups (n = 20 in each). Patients received, at skin closure via the epidural catheter, 100 mg tramadol (Group I), 200 mg tramadol (Group II) or 10 ml saline (Control group). Pain scores and side effects were evaluated at 1, 2, 4, 8, 12 and 24 hr after surgery. Mean times to the first analgesic administration, as well as the cumulative doses of analgesic requirements over 24 hr postoperatively were compared.
RESULTS: The mean time to first analgesic administration was longer in patients who received 100 mg tramadol (4.5 +/- 3.1 hr) and the 200 mg tramadol (6.6 +/- 3.4 hr) than in those who received placebo (2.8 +/- 2 hr). The mean cumulative doses of meperidine over 24 hr were less in the 100 mg tramadol group (0.3 +/- 0.3 mg x kg(-1)) and the 200 mg tramadol group (0.3 +/- 0.3 mg x kg(-1)) than in the control group (0.7 +/- 0.4 mg x kg(-1)). Also, the mean doses of diclofenac over 24 hr were less in the 100 mg tramadol group (156 +/- 59 mg) and the 200 mg tramadol group (142 +/- 62 mg) than in the control group (214 +/- 70 mg). However, no difference was obtained between patients receiving 100 mg and 200 mg tramadol concerning all parameters studied.
CONCLUSION: Epidural tramadol 100 mg can provide adequate postoperative analgesia without respiratory depression in patients after Cesarean delivery [citas]
2. Epidural anaesthesia and analgesia: better outcome after major surgery? Buggy D. Smith G. BMJ 1999; 319: 530-31. Editorials. 
Growing evidence suggests so: Major surgery induces profounds physiological changes in the perioperative period, characterised by increases in sympathoadrenal and other neuroendocrine activity and also increased cytokine production. Because epidural anaesthesia can attenuate this "stress response" to surgery, improve the quality of postoperative analgesia in comparison with systemic opioids, and hasten recovery of gut function, it has been suggested that conducting surgery under epidural anaesthesia (either as the sole anaesthetic or in combination with general anaesthesia) may reduce perioperative morbidity and mortality compared with general anaesthesia alone (1). Indeed, in a study of high risk patients undergoing major vascular surgery those who received combined general and epidural anaesthesia with postoperative epidural analgesia had significantly lower cardiac morbidity than those receiving general anaesthesia alone with postoperative systemic opioid analgesia.(2) Unfortunately, subsequent studies have failed to confirm this finding. This uncertainty probably relates to the design, small size, and inadequate number of relevant studies for a meta-analysis of outcome; hence investigators in Australia are currently undertaking a large, multicentre study to address this question. Though the effects of epidural anaesthesia on mortality and cardiac morbidity have been disappointing so far, the evidence that epidural anaesthesia decreases thromboembolic, pulmonary, and gastrointestinal postoperative complications is much more encouraging. A meta-analysis showed a significant reduction in venous thromboembolism in patients undergoing surgery for hip fracture under regional (epidural or spinal) anaesthesia compared with general anaesthesia, but showed only a marginally better effect on early mortality.(3) Another meta-analysis of randomised controlled trials on the influence of different anaesthetic and postoperative analgesic regimens on pulmonary outcome found that thoracic epidural anaesthesia and analgesia using opioids and local anaesthetics was associated with a decreased incidence of atelectasis, pulmonary infections, and hypoxaemia compared with systemic opioids.(4) Perhaps surprisingly, there were no differences in physiological lung volumes. The mechanism by which thoracic epidural anaesthesia improves pulmonary morbidity is unclear but may be related to improved analgesia and alertness, allowing patients to sigh, cough, and change position more easily. Diaphragmatic dysfunction, a consequence of reflex muscle spasm after surgery, may also be attenuated by thoracic epidural anaesthesia, hence improving pulmonary function.(5) It is in gastrointestinal surgery, however, that epidurals have most often shown favourable effects on outcome. Postoperative ileus is a ubiquitous complication after major abdominal surgery, inhibiting gut motility for up to 72 hours and prolonging admission. In a randomised trial patients undergoing major abdominal surgery using combined general and thoracic epidural anaesthesia had earlier recovery of gut function than those receiving general anaesthesia alone followed by standard systemic opioid analgesia.(6) Optimum results ar achieved when the epidural regimen combines local anaesthetics and opioids, as sole use of epidural morphine may delay recovery of gut motility and cause pruritus and nausea. (6, 7) The mechanism of its apparent efficacy could be due to segmental block of dermatomes T5-T12, antagonising sympathetically mediated peristaltic inhibition while preserving vagal and sacral parasympathetic outflow. As postoperative pain may be a potent cause of adverse events in many organ systems,(8) the improved postoperative analgesia afforded by continuing epidural analgesia has prompted investigations on whether it facilitates resumption of oral nutrition, mobilisation, and earlier discharge from hospital or intensive care units. Improved patient activity at 3.5 weeks and less pain enduring to 9.5 weeks after operation have been shown in a prospective, double blind study of patients undergoing radical prostatectomy with pre-emptive epidural anaesthesia.(9) Another retrospective investigation in patients undergoing oesophagectomy showed that those who received intraoperative and postoperative thoracic epidural anaesthesia, early tracheal extubation,and intensive physiotherapy were mobilised and discharged from intensive care more rapidly than those receiving conventional management.(10). Though these reports are promising, translating improvements in physiological variables achieved by epidurals into significantly better postoperative clinical outcomes may be difficult and may be confounded by cultural or psychological factors.Patients undergoing major surgery may expect to stay in hospital for 7-10 days, necessitating that carers in these outcome studies should be blind to such factors as whether conventional or laparoscopic surgery was conducted.(11) Indeed, the combination of epidurals, laparoscopic surgery, and a multimodal approach to aggressive postoperative rehabilitation may dramatically reduce hospital stay, as shown in nine elderly patients who stayed in hospital for only two to three days after colonic surgery, compared with the normal 10 days.(12) This was, however, an open investigation, and larger studies, necessary for proper evaluation of this multimodal approach, have not yet materialised. Consideration of these studies raises the question of the adequacy of current outcome variables for evaluating recovery. Modern anaesthetic practice inherently safe and differences in mortality between techniques may be difficult to detect,even in high-risk patients. Thus future postoperative outcome studies may need to focus on patients' own views of recovery, including their assessment of their overall well being and return to preoperative energy and activity levels. Despite the evidence that use of epidural anaesthesia is associated with some improvements in postoperative outcome, it carries the risk of serious neurological complications. These are rare, but vigilance in the postoperative period is required to detect the triad of back pain, progressive motor weakness, and incontinence which may herald an epidural haematoma or abscess. Modern practice using dilute concentrations of local anaesthetics or opioids in epidural infusions (thereby reducing motor weakness) is helpful in aiding diagnosis of this potentially devastating complication. If suspected, immediate radiological investigation (with magnetic resonance imaging) and surgery are required to relieve spinal cord compression. Thus, the balance of available evidence in the form of relatively few randomised trials and meta-analyses suggests that epidural anaesthesia and postoperative analgesia may facilitate earlier recovery and improved outcome by reducing the incidence of thromboembolic, pulmonary, and gastrointestinal complications after major surgery. A multidisciplinary approach to rehabilitation may help to capitalise on this improved postoperative physiological state, but further prospective evaluation is warranted.

Donal J Buggy, senior lecturer.  Graham Smith, professor.
University Department of Anaesthesia and Pain Management, Leicester
General Hospital, Leicester LE5

BIBLIOGRAFY.
1.- Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78: 606-617[Medline].
2.- Yeager MP, Glass DD, Neff RK, Brinck-Johnsen T. Epidural anesthesia and  analgesia in high-risk surgical patients. Anesthesiology 1987; 66: 729-736[Medline].
3.-  Sorenson RM, Pace NL. Anesthetic techniques during surgical repair of femoral  neck fractures. A meta-analysis. Anesthesiology 1992; 77:1095-1104[Medline].
4.-  Ballantyne JC, Carr DB, deFerranti S, Suarez T, Lau J, Chalmers TC, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomised, controlled trails. Anesth Analg 1998; 86: 598-612[Medline].
5.-  Manikian B, Cantineau JP, Bertrand M, Kieffer E, Sartene R, Viars P. Improvement of diaphragmatic function by a thoracic extradural block after upper abdominal surgery. Anesthesiology 1988; 68: 379-386[Medline].
6.-   Liu SS, Carpenter RL, Mackey DC, Thirlby RC, Rupp SM, Shine TS, et al. Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology 1995; 83: 757-765[Medline].
7.-   Smith G, Power I, Cousins MJ. Acute painis there scientific evidence on which  to base treatment? Br J Anaesth 1999; 82: 817-819.
8.-  Mangano DT, Siliciano D, Hollenberg M, Leung JM, Browner WS, Goehner P, et al. Postoperative myocardial ischaemia. Therapeutic trials using intensive analgesia  following surgery. The Study of Perioperative Ischaemia
Research Group. Anesthesiology 1992; 76: 342-353[Medline].
9.-   Gottschalk A, Smith DS, Jobes DR, Kennedy SK, Lally SE, Noble VE, et al. Pre-emptive epidural analgesia and recovery from radical prostatectomy. A randomized controlled trial. JAMA 1998; 279: 1076-1082[Medline].
10.-   Brodner G, Pogatski E, Van Aken H, Buerkle H, Goeters C, Schulzki C, et al. A  multimodal approach to control postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy. Anesth Analg1998; 86: 228-234[Medline].
11.-  Majeed AW, Troy G, Nicholl JP, Smythe A, Reed MWR, Stoddard CJ, et al.  Randomised, prospective, single-blind comparison of laparoscopic versus small-incision cholecystectomy. Lancet 1996; 347: 989-994[Medline].
12.     Bardram L, Funch-Jensen P, Jensen P, Crawford ME, Kehlet H. Recovery after laparoscopic colonic surgery with epidural analgesia, early oral nutrition and mobilisation. Lancet 1995; 345: 763-764[Medline] [citas]

3. Safety of Continous Epidural Anesthesia during Heart Surgery. Change of Coagulation and Fibrinolysis under Heparinization.  Maeda M, Kosaka Y,Kushizuki H, Yamamori Y, Haishimoto K, Saito Y.  Department of Anesthesia. Shimare Medical University. Izumo. Japan. Masaui. 1999; 48: 723-30.
To confirm the safety of continuous epidural anesthesia during extracorporeal circulation under heparinization, we investigated epidural hematoma formation following the cardiopulmonary bypass in both humans and dogs. In fifteen dogs, divided into three groups, heparin was administered at the dose of 300, 600, or 900 U/kg, respectively. In fourteen patients, a dose of 300 U/kg heparin was administered for cardiopulmonary bypass. Although blood coagulation-fibrinolysis dropped into abnormal ranges following heparinization, no epidural hematoma was observed in dog and no patient revealed spinal complication associated with epidural hematoma. These data indicate that continuous epidural anesthesia would be a safe tool for intraoperative anesthesia even during extracorporeal circulation under heparinization [citas]
4. Rectal Indomethacin reduces postoperative pain and morphine use after cardiac surgery. Rapanos T, Murphy P, Szalai JP, Burlacoff L, Lam-McCulloch J, Kay J. Department of Anaesthesia, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Ontario, Canada. Can J Anaesth. 1999; 46: 725-30.
PURPOSE: To evaluate the combination of rectal indomethacin with patient controlled intravenous morphine analgesia (PCA) on postoperative pain relief and opioid use after cardiac surgery.
METHODS: With institutional ethics approval, 57consenting adults  undergoing elective aortocoronary bypass
surgery were randomly assigned preoperatively in a double-blind fashion to receive either placebo (n =26) or indomethacin 100 mg suppositories (n = 31), 2-3 hr postoperatively, and12 hr later. Both groups utilized PCA
morphine. Pain scores in the two treatment groups were assessed on a 10-cm visual analogue scale (VAS) (at rest and with cough) at 4, 6, 12, 18 and 24 hr after initial dosing, and were analyzed through a 2 x 5 repeated measures of variance. The 24 hr analgesic consumption, 12 and 24 hr chest tube blood loss, and time to tracheal extubation were also recorded, and compared for the two treatment arms through Student's t test on independent samples.
RESULTS: Postoperative morphine consumption in the first 24 hr was 38% less in the indomethacin group (22.40+/- 12.55 mg) than the placebo group (35.99 +/- 25.84 mg), P = 0.019. Pain scores, measured with a VAS, were 26% to 66% lower in the indomethacin vs placebo group at rest (P = 0.006), but not with
cough, for all times assessed. There was no difference in blood loss (at 12 hr) or time to tracheal extubation for both groups.
CONCLUSION: The combination of indomethacin with morphine after cardiac surgery results in reduced postoperative pain scores and opioid use without an increase in side effects [citas]
5. Subarachnoid fentanyl with diluted small-dose bupivacaine for cesarean section delivery. KanFC- Tsai YC.Chang PJ.Chen TY. Acta Anaesthesiol Sin 1998 36 ; 4 :207-14. Department of Anesthesiology, National Cheng Kung University, College of Medicine,Taiwan, R.O
BACKGROUND: The use of neuraxial opioid was very popular in recent years and they augment  the analgesia produced by local anesthetic through direct binding  with the spinal opioid receptors. Hemodynamic stability is very important during sesarean section. Theoretically, the reduction of local anesthetic by addition of fentanyl would provide better hemodynamic stability and good anesthetic status.
METHODS: Thirty healthy parturients undergoing cesarean section were assessed in a randomized fashion. They were divided into two groups. Each subject received 5 mg hyperbaric bupivacaine plus 25 micrograms fentanyl (0.5 ml) and cerebrospinal fluid (CSF) 0.6 ml (Group M + F) or 8 mg hyperbaric bupivacaine plus 0.5 ml of CSF (Group M). The effects of hemodynamic stability, side effects, and complete analgesic duration were observed.
RESULTS: It was disclosed that the hemodynamic status was more stable in group M + F. The incidence of nausea and vomiting appeared to be not statistically significant between groups. The incidence of pruritus was apparently higher in group M + F (93.5% vs. 0) but the incidence of shivering was much lower in group M + F (0 vs. 33.3%). The complete analgesic duration was longer in group M +F (146 +/- 47 min vs. 104 +/- 44 min). There were no significant differences in the anesthetic and surgical status, 1-min and 5-min Apgar scores, and the time of regression of sensory level to T10.
CONCLUSIONS: The combination of small-dose bupivacaine with fentanyl could provide more stable hemodynamic status, longer postoperative analgesia, and lower incidence of shivering. The incidence of pruritus in group M + F was high, but it was usually mild  [citas]
6. Postdural puncture headache is not an age-related symptom in children: a prospective, open randomized, parallel group study comparing a 22-gauge Quincke with a 22-gauge Whitacre needle. Kokki H, Salonvara M, Hrerrgard E, Onen P. Paediatr. Anaesth. 1999; 9:5.429-434.
Many reports have shown a low incidence of postdural puncture headache (PDPH) and other complaints in young children. The objective of this open-randomized, prospective, parallel group study was to compare the use of a cutting point spinal needle (22-G Quincke) with a pencil point spinal needle (22-G Whitacre) in children. We studied the puncture characteristics, success rate and incidence of postpuncture complaints in 57 children, aged 8 months to 15 years, following 98 lumbar punctures (LP). The patient/parents completed a diary at 3 and 7 days after LP. The response rate was 97%. The incidence of PDPH was similar, 15% in the Quincke group and 9% in the Whitacre group (P=0.42). The risk of developing a PDPH was not dependent on the age (r<0.00, P=0.67). Eight of the 11 PDPHs developed in children younger than 10 years, the youngest being 23-months-old [citas]
7. Prevention of hypotension after spinal anesthesia for cesarean section: dextran 40 versus
lactated Ringer's solution. Lin CS, Lin TY, Huang CH, LIN YH. Lin CR. Chan WH, Tsai SK. Acta Anesthesiol Sin. 1999; 37; 55-59.
BACKGROUND: This study was designed to compare the efficacy of 10% dextran 40 with lactated Ringer's (LR) solution in reducing the incidence and severity of hypotension after spinal anesthesia for Cesarean section.
METHODS: Sixty ASA grade patients scheduled for Cesarean section were randomized into two groups in a double-blind fashion to receive either 500 ml of dextran 40 or 1000 ml of LR solution prior to induction of spinal
anesthesia.
RESULTS: The incidence of hypotension was 16 in 30 (53.3%) in the LR solution group and 8 in 30 (26.7%) in the dextran group (P< 0.05). The required dose of ephedrine for treatment of hypotension was significantly greater in the LR solution group than in the dextran group (15.5 mg versus 3.2 mg, P<0.05). Neonatal outcome, as determined by Apgar score, was good and similar in both groups.
CONCLUSIONS: We concluded that 500 ml of dextran 40 is more effective than 1000 ml of lactated Ringer's solution in reducing the incidence of hypotension induced by spinal anesthesia [citas]
8. Double-blind evaluation of optimal dosage for analgesia after major lumbar spinal surgery. Boezaart AP, Eksteen JA, Spuy GV, Rossouw P, Knipe M. Spine 1999; 24: 1131-1137. 
STUDY DESIGN: A prospective, randomized, double-blind study.
OBJECTIVES: To evaluate the efficacy and safety of three different dosages of intrathecal morphine sulfate for postoperative analgesia after lumbar spinal fusion.
SUMMARY OF BACKGROUND DATA: Analgesia and respiratory depression after intrathecal morphine sulfate injection are dose related. The optimal dose to use for major spinal surgery is not known.
METHODS: Sixty patients undergoing posterolateral lumbar fusion with or without decompression were divided randomly into 3 groups of 20 patients each. Anesthesia, monitoring, and surgery were similar for all patients. Just before closing of the wound, morphine sulfate was injected into the dural sack under direct visualization. Patients in groups 1-3 received 0.2 mg, 0.3 mg, and 0.4 mg morphine, respectively. Routine analgesia, consisting of diclofenac, was prescribed to use if necessary. Measurements were made and compared between the groups at zero hours (on admission to the Intensive Care Unit), 6 hours, 12 hours, 18 hours, and 24 hours after surgery.
RESULTS: At  zero hours and at 12 hours after surgery, pain levels were similar in groups 2 and 3, but were significantly higher in group 1 (P<0.05). The respiratory rate was significantly lower in group 3 than in the other two groups (P<0.05), and the arterial CO2 tension (PaCO2) was consistently higher in group 3. PaCO2 decreased in all three groups over the first 24 hours. Pruritus and nausea did not differ among the three groups.
CONCLUSIONS: For adult patients undergoing posterolateral lumbar fusion, 0.3 mg (0.004 mg/kg) is probably the optimal dose of intrathecal morphine to manage pain [citas]
9. Very low dose intrathecal morphine (ITM) provide effective analgesia and minimazes side effects (SE) after coronary artery bypass graft surgery (CABG). Goldstein S, Cocozello K, Pantin E, Hessen A, Grubb W. Vanstrum GS et al. Anesth Analg 1988;67:261-7.
INTRODUCTION: (ITM) provides effective analgesia after CABG (1). However, (SE) limit it's use. The goal of this study was to determine if very low dose ITM would provide effective analgesia and minimize SE.
METHODS: After informed consent, 35 patients (pts) for CABG were prospectively randomized in a double blind fashion to group1 IT saline (ITS), (group 2) 4.25ucg/kg ITM, or (group 3) 7 ucg/kg ITM. Anesthetic was standardized. Postop, patients had IV PCA morphine (IV PCA M). Visual analogue scale (0-10) was used to score: chest pain (CP), leg pain (LP), (N), and pruritis (P) every 4 hrs for 48 hrs. RR/min was measured at the same intervals. Groups were compared for mcg/kg IV PCA M for 48 hrs (MS48) and hrs in ICU until patients performed 3 extubation criteria (ExtubCrit): negative inspiratory pressure - 30 cmH2O, vital capacity 12 cc/kg, and 5 sec head lift. Means ± SD were compared between groups. Statistical analysis: Kruskal-Wallace ANOVA, P Š 0.05 significant. If significant differences found, Wilcoxon Rank Sum Test with Bonferroni correction.
RESULTS: Chest pain was less in group 2 (0.9 ± 0.74), n=13, vs Grp 1 (2.4 ± 1.45), n=13, (p=0.02). Group 3 chest pain (1.2 ± 1.08), n = 9, fell just short of statistical significance vs group 1 (2.4 ± 1.45) (p=0.06). There was no difference in chest pain in groups 2 and 3 (NS) ). Leg pain was less in group 2 (0.1 ± 0.14) vs group 1 (1.0 ± 1.71) (p=0.02). LP in group 3 (0.3 ± 0.64) was not different vs group 1 (1.0 ± 1.71) (p = 0.42), or group 2 (p = NS) (see table1). N (p=0.3), P (p=0.3), RR (p=0.6), ExtubCrit (p=0.8) and MS 48 (0.13) were not different between groups.
DISCUSSION: 4.25 mcg/kg ITM improved analgesia vs placebo, and did not worsen N, pruritus, extubation criteria, or respiratory rate. Reports of side effects may be due to excess dosing. Chest pain in 7 mcg/kg ITM group was not different from 4.25 mcg/kg group. 4.25 mcg/kg ITM provides effective analgesia after CABG and minimizes side effects.
 
Table 1. Visual Analogue Scores for Analgesia
Group
Chest pain
Leg pain
Placebo
2.4 ± 1.45
1 ± 1.71
4.25 mcg/kg ITM
0.9 ± 0.74*
0.1 ± 0.14*
7 mcg/kg ITM
1.2 ± 1.08
0.3 ± 0.64
Scores are reported as means ± S.D.  * = Statistically significant as compared to placebo (p=0.02).
[citas]
10. Epidural anesthesia has general anesthetic effects. Peter S. Hodgson, M.D.; Spencer S. Liu, M.D.; Troy W. Gras, B.S. Virginia Mason Medical Center, Seattle, WA, USA.
BACKGROUND: During combined epidural/general anesthesia, surprisingly low end-tidal concentrations of volatile agents suppress consciousness. Neuraxial anesthesia exhibits sedative properties which may reduce requirements for general anesthesia. (Anesth Analg:81:525-8, 1995 2.Anesthesiology:80:253-260, 1994.) We tested whether epidural lidocaine reduces volatile anesthetic requirements as measured by the MAC of sevoflurane using a noxious stimulus cephalad to the sensory block.
METHODS: After receiving midazolam 0.02 mg/kg and fentanyl 1mcg/kg, 44 patients were randomized to 300 mg epidural lidocaine (group E), epidural saline (group C), or epidural saline/intravenous lidocaine infusion (group I). Tracheal intubation followed a standard induction with thiopental 4mg/kg, succinylcholine 1 mg/kg, and sevoflurane. After 10 minutes of stable end-tidal sevoflurane, 10 seconds of 50Hz, 60 mA tetanic electrical stimulation were administered in the C5 dermatomal distribution. (2) The MAC for each group was determined  by the up-and-down method and probit analysis based on patient movement.
RESULTS: MAC of sevoflurane for group E, 0.52 ±0.18% (± 95%CI), differed significantly from group C, 1.18 ± 0.18% (p<0.0005), and from group I, 1.04 ± 0.18% (p<0.001). The plasma lidocaine levels in groups E and I were comparable (approx. 3 mcg/ml).
CONCLUSIONS: Lidocaine epidural anesthesia reduced the MAC of sevoflurane by approximately 50%. This MAC-sparing is most likely due to central sedative effects of spinal deafferentation and not to systemic effects of lidocaine or direct neural blockade. The apparent general anesthetic effects of epidural anesthesia should allow decreased use of volatile agent during combined epidural/general anesthesia, which may prevent hemodynamic inestability and hasten emergence and recovery [citas]
11. Wrist and finger blood pressures compared to arterial line measurements.Michael C. Bartfield, MD, S.J. Carlan, MD, Gregory Zittel, MD, Terrence Peppy, MD, Rachel Humphrey, MD. (Obstet Gynecol 1999;93:24. © 1999 by The American College of Obstetricians and Gynecologists.) Orlando Regional Healthcare System, Orlando, FL, USA.
PURPOSE: To determine the accuracy and precision of finger and wrist blood  pressure measurements when compared to direct cutaneous intraarterial measurements in pregnant women.
METHODS: All patients were at greater than 20 weeks of gestation withan intraarterial line in place for reasons other than the study. Measurements using Dinamap, standard wall mercury sphygmomanometer, electronic digital blood pressure, and digital wrist blood pressure were obtained in rapid succession on the extremity opposite the arterial line.
RESULTS: Fourteen women were enrolled in the study, and there were 1,289 observations recorded. Mean maternal age was 25.7 years, and mean gestational age was 33.9 weeks; 93% of the patients were on magnesium sulfate and 71% on labetalol at the time of the study. There is no significant difference between direct arterial measurements and wrist systolic (-2.3 ± 23.3 mm Hg), wrist diastolic (-3.8 ± 12.3 mm Hg), and finger diastolic (4.6 ± 5.9 mm Hg) measurements.
CONCLUSIONS: 1) Although the mean values confirmed that there was no overall satistical significance between selected important measurements, the range of values between intraarterial values in both the finger and wrist cuff measurements was very wide, suggesting caution should be used when interpreting individual results. 2) These devices may be helpful in measuring serial blood pressures because they are relatively inexpensive and
easy to use [citas]
12. The incidence of unanticipated difficult intubation in 6742 General Surgical patients. Kayoko Okazaki, MD; Noriaki Kanaya, MD; Yukitoshi Niiyama, MD; Yasuyuki Honma, MD; Akiyoshi Namiki, MD. 
Sapporo Medical University School of Medicine, Sapporo, Japan
INTRODUCTION: Occasional difficulty in tracheal intubation (INT) is a feature of clinical anesthesia. Although the incidence of the difficult INT is low (1-4%) in general surgical and obstetrical patients, interruption of gas exchange can result in catastrophic outcomes such as brain damage or death. Especially, unanticipated difficult INT can cause a life-threatening scenario because of less preparation including alternative to mask ventilation, and absence of breathing. However, there have been no systematic approach to examine the incidence of unanticipated difficult INT in large number of patients. The purpose of this study was to examine the incidence of unanticipated difficult INT in all patients attended by anesthesiologists.
METHODS: During a three year period (1996-1998), the incidence of difficult INT was monitored via a quality assurance data collection system. Difficult INT was defined by the ASA Task Force as occurring when "proper insertion of the tracheal tube with conventional laryngoscopy requires more than three attempts or more than 10 minutes". Prediction of difficult INT was assessed by the visibility of oropharyngeal structures (Class I-IV in Mallampati Classification, Samsoon modified). Direct laryngoscopic view was determined by Cormack and Lehane Classification. Patients with pre-existing airway abnormality (e.g. limitation of mouth opening and head extension, et.al.) were excluded in this study.
RESULTS AND CONCLUSIONS: For 6742 patients following a direct laryngoscopy, tracheal INT was difficult in 4.9%. The incidence of difficult INT in patients with a good (Class I and II) and poor (Class III and IV) oropharyngeal view was 3.4% and 1.5%, respectively. In the patients with a good oropharyngeal view, achieving a good laryngoscopic view (Grade 1/2 in 72%) was greater than a poor view (Grade 3/4 in 28%). These results suggests that unanticipated difficult INT is more commonly seen in total difficult INT than anticipated difficult INT. A good view during direct laryngoscopy does not guarantee success INT. Thus, every anesthesiologists should be familiar with and well practiced in a variety of the techniques for unanticipated difficult INT [citas]
13. The anesthetic management of a preterm infant weighing 500 grams undergoing ligation of patent ductus arteriosus (case report). Acta Anesthesiol Sin 1999; 37: 89-92. Department of Anesthesiology, China Medical College Hospital, Taichung,Taiwan. Chen KB, Tu KT, Cheng HC, WU YL, Chang JS.
PDA (patent ductus arteriosus) is a common congenital heart disease. Usually surgical intervention through left thoracotomy or recently through video assisted thoracoscopy will be recommended if the preceding or intent medical treatment fails or is contraindicated. However, once surgical intervention is decided, various complications are still a real fear in the mind of the surgeon and the anesthesiologist, particularly if the infant is premature or very sick. Here we report an anesthetic management in a female preterm infant weighing 500 grams, who underwent PDA ligation. She was born at gestation age of 28 weeks at our hospital, and since her birth she was noted to have infant respiratory distress syndrome associated with renal dysfunction. She was admitted to the neonatal intensive care unit (NICU) straightaway. After thorough examination, a severe PDA was disclosed. The possibility of pulmonary hemorrhage and heart failure could be predicted in view of the large left to right shunt. Worst of all was that her poor renal function contradicted a medical treatment. So we decided to carry out the ligation procedure at once although she was premature and only 5 days old. The NICU was chosen as the operation theater for transferring concerns. General anesthesia was induced and maintained by atropine 0.01 mg, pancuronium 0.1 mg, fentanyl 2 micrograms, and ketamine 0.15 mg intravenously. Supplemental oxygen was given throughout the operation. The PDA was ligated through left thoracotomy and blood loss was minimal. The peri-operative course was uneventful. The patient recovered well following surgery and anesthesia [citas]
14. Farmacología del rapacuronio. Un nuevo relajante muscular no despolarizante. El presente es un artículo que se publicará en la Revista Argentina de Anestesióloga en su No.5 (noviembre). Miguel Angel Paladino, Marcelo Nigro.
INTRODUCCION: Los nuevos relajantes no despolarizantes deben brindar al anestesiólogo la posibilidad de elegir el fármaco preciso en cada una de las diversas intervenciones quirúrgicas, con escasos riesgos y adecuada estabilidad hemodinámica. Los estudios clínicos farmacológicos en el campo de estas drogas se orientan a conseguir modificaciones en algunos de los siguientes aspectos: 1. Rapidez en el comienzo de acción  para permitir una rápida intubación traqueal; 2. Cambios posibles en la  previsibiliad del fin de la acción sin bloqueo neuromuscular residual; 3. Disminuir los efectos cardiovasculares y autonómicos; 4. Diversas  farmacocinéticas acordes con diversas patologías, y, 5. Distintos tiempos de acción para adaptarlos a diversas situaciones clínicas y terapéuticas. Durante décadas, se intentó encontrar un relajante muscular no despolarizante que tuviera un tiempo de latencia o comienzo de acción ultracorto similar a la succinilcolina, pero libre de los posibles efectos colaterales que ésta puede producir. Con la aparición del rocuronio, relajante muscular no despolarizante aminoesteroideo, se avanzó en algunos de los aspectos considerados. Su inicio de acción es rápido, a los sesenta segundos el paciente puede ser intubado, en condiciones similares a la succinilcolina sin liberación de histamina, sin cambios hemodinámicos, ni a nivel vagal y ganglionar. Un nuevo relajante de este grupo se ha estado estudiando durante la década del 90, bajo la sigla de ORG9487, cuyo nombre genérico es rapacuronio o rapacuronium. Diversos estudios se han realizado y llegó a la fase 3 de estudio clínico en 1996. El rapacuronio fue introducido para su uso en clínica  en 1998, y constituye la última novedad en relajantes musculares. Diversos artículos en las principales revistas de la especialidad han sido publicados en los últimos meses. Esto  ha llevado al comité de redacción de la revista conjuntamente con el Cop de medicamentos a presentar sus principales características, y su perfil farmacológico. La misma probablemente esté disponible comercialmente en nuestro país en el año 2000 o 2001. Las modificaciones en el grupo éster 17 y en la estructura cicloamino de los sustituyentes del esqueleto androstano del vecuronio, llevó a la síntesis del rocuronio (propionato análogo del vecuronio). Se diferencia del vecuronio y del rocuronio por su muy alto aclaramiento plasmático y menor tiempo medio de estadía en el receptor. En plasma se detecta el metabolito 3-OH que posee actividad relajante muscular. Su principal característica  es que al ser antagonizado con neostigmina a los dos minutos de administrado, la duración de su efecto es aproximadamente de 10 a 20 minutos. Su potencia farmacológica es baja. Esta característica le confiere la mayor parte de sus propiedades diferenciales con el resto de los relajantes antidespolarizantes, salvo el rocuronio.
FARMACODINAMIA: Los relajantes musculares no despolarizantes de menor potencia (los que necesitan mayor número de moléculas para producir un efecto similar a otro) tendrán un comienzo de acción más rápido
que los de menor potencia. Para determinar la velocidad de comienzo y la duración de la acción clínica de los relajantes los factores fundamentales a tener en cuenta son: 1. La perfusión de la unión neuromuscular, y por lo tanto la difusión desde  del compartimento central (plasma) a la hendidura sináptica donde está el receptor; 2. La velocidad de asociación del compuesto con el receptor; 3. La unión con receptores inespecíficos. El primer punto depende fundamentalmente de variables hemodinámicas del paciente como gasto cardiaco, presión de perfusión del músculo, resistencias periféricas etc. El segundo y tercer punto, vemos que, rápidas velocidades de comienzo dependen de rápidas velocidades de asociación con el receptor y de la incapacidad de unirse a receptores inespecíficos. Por otra parte, para que se produzca bloqueo neuromuscular se necesita que un gran número de receptores se encuentre ocupado por moléculas de relajante, por lo tanto teóricamente, cuanto mayor sea el número de moléculas administradas o menor sea su volumen de distribución,  más rápido resultará el comienzo de acción. La DE90 del rapacuronio se ha establecido en 1.15 mg/kg, siendo la dosis utilizada normalmente en clínica 1.3 x DE90 (1.5 mg/kg.). Otra característica de la droga es que el comienzo de acción, es más rápido en musculatura laríngea que en musculatura periférica; 52 vs 62 segundos, la intensidad del bloqueo es menor en laringe que en la musculatura periférica (86 vs 97%), siendo la duración del efecto menor en  la región laríngea que en periférica (3.7 vs 10.2 minutos). Se ha postulado que su capacidad para inhibir los canales de calcio voltaje dependiente permite una vasodilatación, con aumento de flujo sanguíneo arterial al músculo y aumento en la velocidad en  la tasa de equilibrio entre plasma y biofase, que puede explicar el rápido comienzo del efecto que produce, sobre todo en los músculos cortos como los laríngeos.
FARMACOCINETICA: Tiene el aclaramiento mayor de todos los relajantes musculares (8.45 ml/kg/min).
Con un alto valor de ke0, lo que le permite un rápido equilibrio entre plasma y biofase, con una t1/2 de distribución rápida, extraordinariamente corta que permite un comienzo de acción similar a la succinilcolina. Se excreta por riñón en cantidades  aproximadas al 17%, el resto lo hace por bilis y por metabolización. Su metabolito activo 3-OH, se acumula. El uso de rapacuronio por un tiempo de más de una hora, puede ser causante de prolongación de su efecto [citas]
15. Anesthesia for in vitro fertilization. A comparision of 1.5% and 5% spinal for ultrasonically guided oocyte retrieval. Manica, Virgil S., MD; Bader, Angela M., MD; Fragneto, Regina, MD; Gilbertson, Lesley, MD; Datta, Sanjay, MD. Anesthesia & Analgesia. 1993; 77 :3. Department of Anesthesia, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts Accepted for publication June 4, 1993. Address correspondence and reprint requests to Dr. Bader, Department of Anesthesia, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.
ABSTRACT: In many institutions, spinal anesthesia is used for surgery involving ultrasonically guided transvaginal oocyte retrieval. Because this relatively short procedure is performed on an outpatient basis, the optimal spinal technique would allow good surgical anesthesia with a short recovery time. The relative regression of equal doses of different concentrations of hyperbaric spinal lidocaine is presented. We compared 1.5% and 5% hyperbaric lidocaine (7.5% dextrose) as spinal drugs for use in this procedure. Fifty-six patients were randomized to  receive 60 mg of hyperbaric solutions of either 1.5% or 5% lidocaine in combination with 10 mcg of spinally administered fentanyl. Visual analog scale pain scores were zero throughout the procedures for all patients. There were no significant differences between the groups with regard to sensory level, maximum motor block, intravenous sedation requirements, time to two-segment regression, and time to full sensory recovery. The group receiving 1.5% lidocaine had significantly shorter times to ambulation (141 ± 21 min vs 162 ± 29 min; P < 0.05), voiding (147 ± 21 min vs 174 ± 28 min; P < 0.05), full motor recovery (86 ± 21 min vs 111 ± 22 min; P < 0.0001), and discharge (170 ± 38 min vs 201 ± 41 min; P < 0.05). The use of 1.5% hyperbaric lidocaine for transvaginal oocyte retrieval provides a significantly shorter recovery time when compared to 5% hyperbaric lidocaine and is a good choice for spinal anesthesia for this procedure,  is relatively short and patients are sent home the same day, the anesthetic method chosen should provide a quick recovery time. Although local anesthesia with sedation can be used, there are some reports of patient dissatisfaction as well as excessive drowsiness. Spinal block would provide excellent surgical anesthesia with minimal need for sedation. The present study compares two hyperbaric lidocaine solutions used in spinal anesthesia for transvaginal ultrasound guided oocyte retrieval with respect to quality of sensory and motor block, side effects, and recovery times. The results of this study provide information not previously published regarding relative regression of equal milligram doses of different concentrations of hyperbaric spinal anesthetics. 
METHODS: The study was approved by the hospital's Committee for the Protection of Human Subjects and written informed consent was obtained from all participants. Fifty-six ASA I and II patients scheduled for ultrasonically guided oocyte retrieval procedures were enrolled. Patients were excluded if height was less than 60 in or greater than 72 in, or if weight was more than 91 kg. Subjects were randomized in a double-blinded fashion to receive spinal anesthesia with either 60 mg of hyperbaric 1.5% lidocaine (4 mL) or 60 mg of hyperbaric 5% lidocaine (1.2 mL) in combination with 10 mg of preservative-free fentanyl. The investigator recording data did not perform the spinal, and so was unaware of which lidocaine concentration had been used. All patients received at least 500 mL of intravenous (IV) lactated Ringer's solution before induction of the anesthetic. They were then taken to the operating room and routine monitors were applied. Spinal anesthesia was induced with subjects in the right lateral decubitus position at either the L2-L3 or L3-L4 interspace, using a 25-gauge Whitacre spinal needle. Patients were immediately placed in lithotomy position. They were provided with supplemental IV sedation with midazolam or fentanyl if required. Sensory level to pinprick measured at the midclavicular line, motor block using Bromage scale (), and pain score on a linear visual analog scale (VAS) () were recorded by an investigator at 1, 2, 3, 4, 5, 10, and 15 min, and then every 15 min after the spinal injection until complete resolution of anesthesia. Side effects and amount of supplemental medication required were noted. Other data collected included duration of the egg retrieval procedures, times to two-segment regression of sensory anesthesia and complete regression of sensory anesthesia, and times from spinal injection to ambulation, voiding, and discharge from the postanesthetic care unit. Criteria for ambulation included stable vital signs, absence of sedative effects, and complete resolution of motor and sensory block. After these criteria were met, patients were discharged when they had voided and were in no discomfort from the surgical procedure. Statistical analysis of the data recorded from the two groups was carried out using Student's t-test, c2 test, and Mann-Whitney test where appropriate. A P value <0.05 was considered statistically significant. 
RESULTS: Both groups of patients were similar with regard to weight, height, and age. The egg retrieval procedures lasted an average of 29 min in both groups. There were no differences in the amount of ephedrine used or the number of patients in each group receiving IV supplementation. The sedation received generally consisted of 1&ndash;2 mg of midazolam for relief of anxiety before the procedure. No patient recorded a VAS score greater than zero during the procedures. There were no significant differences in maximum motor and sensory levels or in time to achieve maximum motor and sensory levels. Times to two-segment regression and full sensory recovery were similar. The group receiving 1.5% lidocaine did have a significantly shorter time to full motor recovery. This group also demonstrated a significantly shorter time to ambulation, voiding, and discharge from the postanesthetic care unit. No significant side effects were reported and none of the patients experienced a postdural puncture headache.
DISCUSSION: Ultrasound guided oocyte retrieval procedures are generally short and performed on an outpatient basis. The optimum anesthetic technique should provide rapid onset of anesthesia, with a solid anesthetic level during the procedure, followed by a rapid recovery with a minimum recovery room stay. A variety of anesthetic methods have been used. General anesthesia is usually reserved for gamete intrafallopian transfer (GIFT) procedures, which involve laparoscopy and immediate replacement of the oocyte and spermatozoa in the distal fallopian tube. There is concern that general anesthesia may reduce the rate of fertilization and cleavage of human oocytes. The duration of oocyte exposure to different inhaled agents adversely influenced oocyte quality. Epidural anesthesia has been proposed as an alternative, but the technique is somewhat more time consuming, which makes this less desirable for a procedure that usually requires a rapid turnover between cases. Local anesthesia with or without IV sedation may be used; however, patients may move at critical times during the procedure and may require significant amounts of sedatives to keep them comfortable, resulting in excessive drowsiness and prolonged recovery room stays. The prolactinemia that occurs after the administration of general anesthetics, droperidol and fentanyl, has been associated with lower plasma progesterone levels and may adversely influence the outcome of the in vitro fertilization procedure. Spinal anesthesia would seem to be an optimal choice, providing good pain relief with minimal exposure of the eggs to anesthetic agents. There are no previous data on the relative regression of equal milligram solutions of different concentrations of hyperbaric spinal lidocaine. The current study shows that 1.5% hyperbaric lidocaine provides shorter recovery and discharge times than 5% hyperbaric lidocaine. Because the total dosage of lidocaine given to either group was the same (60 mg), the reasons for these differences in recovery must depend upon other
factors, such as the different volumes injected (4 vs 1.2 mL) and the different concentrations of the solutions (5% vs 1.5%). The same microgram dose of fentanyl was administered in both groups, resulting in different concentrations of fentanyl in the two volumes used. We would not expect this concentration difference to affect sensory and motor recovery. Both groups of patients had excellent analgesia during the procedures, as VAS scores demonstrated. The effects of different volumes of injectate on onset times and extent of block have been examined. A previous study by Vucevic and Russell compared women who received 3 mL of 0.5% isobaric bupivacaine with women receiving 12 mL of 0.125% isobaric bupivacaine for cesarean delivery. Women who received the higher volume had a significantly wider spread of sensory anesthesia initially, but all differences were absent after 5 min. Unfortunately, this study did not assess patients after 60 min of anesthesia, so differences in recovery time could not be determined. There are no similar studies involving hyperbaric local anesthetic solutions. We are the first to compare onset and recovery times when different volumes, but the same dose of local anesthetic, are used for spinal anesthesia. There are no currently published data that would help to elucidate the mechanism underlying the differences in behavior of these two local anesthetic solutions. We can postulate that the higher volume solution may have a higher initial spread into the upper dermatomes, resulting in less total drug per segment and a less dense block overall. The group receiving 1.5% lidocaine did show a trend toward a shorter time to maximum sensory level, although this difference was not statistically significant. The lesser volume of the more highly concentrated solution of 5% lidocaine may have a tendency to settle initially in the lower part of the spinal canal, producing a more dense motor block in the lower extremities with a longer regression time. The higher concentration may also result in more penetration of the nerves closer to the site of injection. Although no differences in maximum motor block were demonstrated between the two solutions, two of the patients in the group receiving 1.5% lidocaine did not achieve a Bromage score of 1. The density of motor block is difficult to evaluate with the Bromage scale, which measures completeness of motor block, but does not adequately rate intensity. A tendency toward longer duration of sensory regression was demonstrated in the 5% lidocaine group (151 min vs 138 min), although this difference did not prove to be statistically significant. In summary, 1.5% hyperbaric lidocaine (60 mg) provides significantly shorter recovery times than does an equal dose of 5% hyperbaric lidocaine for spinal anesthesia for transvaginal oocyte procedures. The differences in regression times between the two solutions provide further information about the actions of spinal anesthetics [citas]
16. An evaluation of the effect of anesthetic technique on reproductive success after laparoscopic pronucleas stage transfer. Propofol - nitrous oxide versus isoflurane - nitrous oxide. Vincent, Jr., Robert D., M.D.*; Syrop, Craig H., M.D.&dagger;; VanVoorhis, Bradley J., M.D.; Chestnut, David H., M.D.§; T.Sparks, Amy E., Ph.D. McGrath, Joan M., M.D.#; Choi, Won W., M.D.**; Bates, James N., M.D. Ph.D. & dagger; Penning, Donald H., M.D.*  Anesthesiology.1995; 82:2.
ABSTRACT: Background: Laparoscopic pronuclear stage transfer (PROST) is the preferred method of embryo transfer after in vitro fertilization in many infertility programs. There are scant data to recommend the use or avoidance of any particular anesthetic agent for use in women undergoing this procedure. The authors hypothesized that propofol would be an ideal anesthetic for laparoscopic  because of its characteristic favorable recovery profile that includes minimal sedation and a low incidence of postoperative nausea and vomiting. The purpose of the study was to compare propofol and isoflurane with respect to postanesthetic recovery and pregnancy outcomes after laparoscopic  PROST.
METHODS: One hundred twelve women scheduled for laparoscopic PROST were randomized to receive either propofol/nitrous oxide or isoflurane/nitrous oxide for maintenance of anesthesia. Results: Visual analog scale scores for sedation were lower in the propofol group than in the isoflurane group at all measurements between 30 min and 3 h after surgery. More women experienced emesis and were given an antiemetic during recovery in the isoflurane group than in the propofol group. However, the percentage of pregnancies with evidence of fetal cardiac activity was 54% in the isoflurane group compared with only 30% in the propofol group (P = 0.023). Also, the ongoing pregnancy rate was greater in the isoflurane group than in the propofol group (54% vs. 29%, P = 0.014). Conclusions: Propofol/nitrous oxide anesthesia was associated with lower clinical and ongoing pregnancy rates compared with isoflurane/nitrous oxide anesthesia. (Key words: Anesthetics, inhalational: isoflurane; nitrous oxide. Anesthetics, intravenous: propofol. Assisted reproductive techniques: pronuclear stage transfer.) IN 1986, Blackledge et al. introduced pronuclear stage transfer (PROST) as a method to enhance the incidence of successful pregnancies in couples with male factor infertility. Subsequently, indications for PROST have expanded, and many reproductive endocrinologists favor this technique for the transfer of preimplantation embryos after in vitro fertilization. Pronuclear stage transfer involves the placement of several one-cell embryos into the distal segment of a fallopian tube during laparoscopic surgery. Several authors have reported that each embryo transferred in this manner has about twice the chance of eventually implanting into the uterine wall compared with those transferred directly into the uterine cavity. Indeed, some studies have found that the incidence of reproductive success after PROST was greater than after transcervical intrauterine embryo transfer. For example, Hammitt et al. reported a clinical pregnancy rate of 52% after PROST procedures compared with only 20% after intrauterine embryo transfers. Despite the increased popularity of PROST, there are no human data to unequivocally promote the use or avoidance of any specific anesthetic agent or technique for the purpose of anesthetizing women for this procedure. Others have noted an adverse effect of isoflurane on preimplantation mouse embryos in vitro. However, the applicability of their findings to human embryo development is questionable because our infertility program has reported high PROST pregnancy rates despite the routine use of isoflurane anesthesia for laparoscopic tubal transfers. Propofol is an excellent anesthetic for outpatient laparoscopic surgical procedures because patients tend to recover quickly with little sedation and nausea. Preliminary laboratory data suggest that it does not harm preimplantation mouse embryos in vitro, but we are not aware of any published clinical data to confirm its safety in humans when administered during embryo transfer procedures. The purpose of the current study was (1) to evaluate measures of reproductive success after administration of either propofol or isoflurane anesthesia for PROST and (2) to confirm whether propofol anesthesia resulted in a more rapid recovery with fewer postoperative side effects compared with isoflurane anesthesia when given for laparoscopic PROST.
METHODS: The protocol was approved by the University of Iowa Human Subjects Review Committee. After hormonal stimulation, preovulatory oocytes were harvested transvaginally followed by insemination with spermatozoa in vitro. Autologous PROST cycles were defined as those transfers in which the oocyte donor and the embryo recipient were the same individual. Donor-recipient PROST cycles were defined as transfers in which oocytes were anonymously donated by a woman other than the one receiving the pronuclear stage embryos. If evidence of successful fertilization (i.e., the presence of two intracellular pronuclei) was present 16&mdash;18 h after insemination, the patient was prepared for laparoscopic PROST. Before surgery, written informed consent was obtained from all women participating in the study protocol. At that time, each participant was randomized to receive either propofol/nitrous oxide or isoflurane/nitrous oxide anesthesia for laparoscopic transfer. Randomization was performed by opening one of a series of sequentially numbered opaque envelopesthat contained the group assignment. The patient, but not the anesthesiologist, was blinded to the group assignment. Individuals who failed to conceive after participating in the study were eligible for a second randomization during a subsequent PROST procedure. Anesthetic Technique General anesthesia was induced with an intravenous bolus of 50&mdash;100 mg fentanyl followed by either 2&mdash; 2.5 mg/kg propofol (propofol group) or 3&mdash; 6 mg/kg sodium thiopental (isoflurane group). Before laryngoscopy and tracheal intubation, 0.4&mdash;0.5 mg/kg atracurium was administered intravenously. A continuous infusion of propofol (£200 mg×kg-1×min-1) was used for maintenance of anesthesia in the propofol group. Isoflurane (£2% inspired) was used for maintenance of anesthesia in the isoflurane group. Nitrous oxide (50%) in oxygen was administered to all patients throughout surgery. In both groups, an additional 50&mdash;100 mcg fentanyl was given during surgery as determined by the attending anesthesiologist. Incremental doses of atracurium were given to maintain adequate neuromuscular relaxation intraoperatively. At the end of surgery, residual neuromuscular blockade was reversed with intravenous glycopyrrolate and neostigmine. Nitrous oxide administration was discontinued at the time of skin closure. (This was defined as time zero for all postoperative measurements.) Surgical Technique After establishing pneumoperitoneum with carbon dioxide, the proximal end of one fallopian tube was identified during laparoscopy and was cannulated with an introducer sleeve. Subsequently, a transfer catheter was advanced through the sleeve, and two or more pronuclear stage embryos were injected into the ampullary portion of the fallopian tube. After verifying that all embryos had been expelled from the transfer catheter, pneumoperitoneum was released and the puncture wounds were closed. All surgeries were performed by one of two faculty reproductive endocrinologists (C.H.S. or B.J.V.) Postoperative Management The first 84 patients were instructed to remain recumbent during the initial 4 h after surgery. (Patients were instructed to refrain from ambulating for several hours after surgery with the hope that this practice would limit any migration of the conceptus within the fallopian tube. Later, this period of strict immobilization was reduced from 4 to 3 h after all other gamete or embryo transfer procedures. At that time, we decided to incorporate this change into our methodology so that the study protocol would be more relevant to current clinical practice at The University of Iowa Hospitals and Clinics. Hence the final 28 women were required to remain recumbent for only 3 h after surgery.) In the recovery room, ice chips and clear liquids were given orally as tolerated. Intravenous morphine (2&mdash;3 mg) or oral acetaminophen with codeine was given as needed to treat postoperative pain. Metoclopramide (10 mg) was administered intravenously for the treatment of persistent nausea. Patients who continued to experience nausea and vomiting after an initial dose of metoclopramide were given either a second intravenous dose of 10 mg metoclopramide or 0.625 mg droperidol at the discretion of the attending anesthesiologist. Patients were discharged from the hospital when they had voided and were able to ambulate, unless they were experiencing significant somnolence, nausea, or pain. Intramuscular progesterone (25&mdash;50 mg) was given daily until results of the chemical pregnancy test(s) were known. If a chemical pregnancy was detected, progesterone administration was continued for at least 2 weeks more. Measurements Patient visual analog scale (VAS) scores for nausea (0 = no nausea and 100 = worst possible nausea) and sedation (0 = wide awake and 100 = almost asleep) were obtained at 15, 30, 60, 120, 180, and 240 min after surgery. (VAS scores at 240 min were not obtained in the final 28 study patients.) At discharge, patients were asked to describe their overall satisfaction with the anesthetic technique as very satisfied (0), somewhat satisfied (1), somewhat dissatisfied (2), or very dissatisfied (3). Patients were unaware of their group assignment until after completion of the discharge questionnaire. Fifteen days after surgery, maternal plasma b-human chorionic gonadotropin concentrations were determined from samples of maternal venous blood to establish whether PROST had resulted in a chemical pregnancy. Positive results were verified with an additional plasma b-human chorionic gonadotropin measurement 48 h later. If a chemical pregnancy was still evident at this time, a vaginal ultrasound examination was performed 24 days after surgery to note the presence and number of gestational sacs within the uterine cavity. If present, an additional ultrasound examination was performed 10 days later to determine whether viable fetal cardiac activity (³100 beats/min) was present. Clinical pregnancies were defined as evidence of viable fetal cardiac activity at that time. Ongoing pregnancies were defined as clinical pregnancies in which spontaneous abortion (of all fetuses) had not occurred. Each gestational sac with fetal cardiac activity was defined as a successful implantation. Implantation rate was calculated as follows: number of successful implantations divided by total number of embryos transferred. Reproductive data were not included in the analysis of pregnancy results if the patient received gamete intrafallopian transfer simultaneous with PROST. Statistical Analysis Comparisons of continuous data between the two groups were made using unpaired t tests. Nonparametric comparisons between groups were made using the chi-square test (2 ´ 2) with contingency correction or the Mann-Whitney U test. Bonferroni adjustments were used in comparing nausea and sedation measurements at specific times. P<0.05 was considered statistically significant.
RESULTS: One hundred twelve PROST cycles were studied between June 1992 and May 1994. Ninety-four women were enrolled once in the study, and nine agreed to participate during two laparoscopic PROST procedures. Among the nine patients who consented to randomization on two instances, three received propofol twice, two received isoflurane twice, and four were given each anesthetic once. There were no significant differences in patient demographic data or infertility factors between the two groups ( and ). Also, the number of embryos transferred during PROST was similar in the two groups (median 4, range 2&mdash;6; for each group). VAS scores for nausea did not differ significantly between the two groups at any time. However, the incidences of vomiting and antiemetic administration were smaller (P<0.05) in the propofol group than in the isoflurane group. The intervals elapsed from the end of surgery until patients could tolerate ice chips or ambulate were each shorter (P<0.05) in the propofol group than in the isoflurane group. Patient VAS sedation scores were significantly lower (P<0.05) in the propofol group than in the isoflurane group at all measurements between 30 min and 3 h after surgery. Also, the interval between the end of surgery and hospital discharge was shorter (P<0.05) after propofol anesthesia than after isoflurane anesthesia. Overall patient satisfaction was high in both groups but was slightly higher (P<0.05) in the propofol group. Four women were not included in the analysis of pregnancy data because extensive tubal disease discovered during laparoscopy precluded successful tubal transfer. Also, two women (isoflurane group) were excluded because they received a gamete intrafallopian transfer procedure in addition to PROST. One of these two patients achieved a singleton ongoing pregnancy. The incidence of chemical pregnancies did not differ significantly between the two groups. However, the percentage of gestations with evidence of fetal cardiac activity was greater (P = 0.023) in the isoflurane group than in the propofol group. Also, the ongoing pregnancy rate was greater (P = 0.014) in the isoflurane group than in the propofol group (54% vs. 29%). The difference in implantation rate after PROST did not differ significantly between the two groups. If the statistical analysis is repeated without reproductive data from all rerandomized transfers, both the incidence of PROSTs resulting in fetal cardiac activity and the implantation rates differed significantly between the two groups (59% vs. 29% and 21% vs. 11%, respectively, in the isoflurane and propofol groups). Discussion Results of laboratory studies could cause one to question the use of isoflurane anesthesia for women undergoing laparoscopic PROST. For example, Chetkowski et al. observed that 30 min of exposure to 1.5% isoflurane reduced the percentage of two-cell mouse embryos developing to the blastocyst stage from 79% to 44%. Despite the accumulation of laboratory data demonstrating potential embryo toxicity from isoflurane, many anesthesiologists continue to administer isoflurane to women undergoing laparoscopic PROST. (Perhaps many, like ourselves, are reluctant to abandon the use of an established anesthetic when pregnancy rates after PROST are already high in their own infertility programs.) The current findings strongly support our earlier clinical impression that isoflurane probably does not exert a substantial detrimental effect on subsequent embryo development and implantation when given during PROST procedures. There are at least two possible reasons why our results appear to contradict earlier studies of mouse embryo development after exposure to isoflurane in vitro. First, because embryos are transferred into the fallopian tube near the conclusion of surgery, concentrations and durations of isoflurane exposure used in laboratory studies may have substantially exceeded the exposure that occurs during PROST. Second, others have challenged the accuracy of the two-cell mouse embryo assay with regard to its ability to predict human reproductive toxicity. However, most of these criticisms have been directed at the assay's low sensitivity not its specificity. Nevertheless, the current results suggest that the two-cell mouse embryo assay has limited clinical application with regard to anesthetic choice for laparoscopic embryo transfer procedures. Others have reported that propofol administration to women undergoing ultrasound-guided transvaginal oocyte retrieval or gamete
intrafallopian transfer does not impair reproductive success. Although these studies involve exposure to human oocytes and not embryos, we hypothesized that pregnancy outcomes after PROST would not be adversely effected by propofol anesthesia. Unexpectedly, pregnancy rates were significantly lower in the propofol group than in the isoflurane group. A random selection bias did not appear to have produced this difference because the number of embryos transferred and the etiologies of infertility were similar in both groups. Ideally, one would prefer to
randomize participants based upon the number of embryos transferred and each couple's specific source of infertility (e.g., male factor, ovarian failure, age, immunologic, endometriosis). For pragmatic reasons, we did not stratify the randomization procedure for source(s) of infertility since this is often not apparent until the time of surgery (i.e., endometriosis). Regardless of the reasons responsible for the differences in pregnancy outcomes observed in the present study, our results suggest the need for careful review of reproductive outcomes in programs that are using propofol anesthesia for PROST procedures. The current investigation did not specifically address the controversy of nitrous oxide administration during PROST. There are conflicting data on the exposure of preimplantation embryos to nitrous oxide. Chetkowski et al. reported that nitrous oxide had no effect on the development of mouse two-cell embryos to the blastocyst stage after exposure in vitro. In contrast, Warren et al. found that 30 min of nitrous oxide exposure inhibited the development of mouse two-cell embryos when given just before the expected onset of cleavage. Our findings add support to the use of nitrous oxide (especially when given with isoflurane) in women anesthetized for embryo transfer procedures. We acknowledge that other factors might have contributed to the observed difference in reproductive success between groups. For example, thiopental was given to all women in the isoflurane group, and metoclopramide was used nearly 10 times as often in the isoflurane group as in the propofol group. Although we find it unlikely that any anesthetic drug increases the probability of reproductive success after PROST, we cannot exclude this possibility. Also, women in the propofol group ambulated sooner than their counterparts in the isoflurane group. It is conceivable that premature ambulation in the propofol group led to extratubular embryo migration. We observed that patients in the isoflurane group were more likely to experience emesis and receive metoclopramide than were women in the propofol group. However, nausea measurements did not differ significantly between the two groups at any time, and no patient required overnight admission for persistent nausea and vomiting. This indicates that, although women in the isoflurane group were more likely to have emesis, their symptoms often resolved rapidly-either spontaneously or in response to metoclopramide. Exogenous hormonal stimulation may have contributed to the lack of severe, persistent nausea in the current study. Beattie et al. observed that perioperative nausea and vomiting were less likely among women who were not close to their time of menstrual bleeding compared to women who were perimenstrual (i.e., cycle days 25 through 4). All women in the current study were in the periovulatory phase (i.e., cycle days 12&mdash;16) of their menstrual cycle as a result of exogenous hormonal stimulation to induce superovulation. Thus, intractable postoperative nausea requiring overnight admission is not a likely event after laparoscopic PROST with either isoflurane or propofol anesthesia. 
SUMMARY: Women who received propofol - nitrous oxide anesthesia had less postoperative sedation and vomiting than similar women given isoflurane - nitrous oxide anesthesia for PROST. However, the clinical and ongoing pregnancy rates after isoflurane/nitrous oxide anesthesia were higher than those after propofol/nitrous oxide anesthesia. Hence, the marginal benefits of propofol anesthesia on postoperative recovery appear trivial given the possibility that propofol unfavorably affects the probability of achieving pregnancy after PROST. These results have prompted us to suspend the use of propofol anesthesia for laparoscopic PROST procedures until the effects of propofol on human preimplantation embryos are better understood. 
The authors thank Karen Holmes, R.N., for her efforts ensuring the accurate and complete collection of all postoperative data. Also, the authors thank Franklin Dexter, M.D., for his advice concerning the statistical methods used in this manuscript, and Michael M. Todd, M.D., for his support of this project. 
REFERENCES
*Assistant Professor, Department of Anesthesia. 
&dagger;Associate Professor, Department of Obstetrics and Gynecology. 
`Assistant Professor, Department of Obstetrics and Gynecology. 
§Professor and Chairman, Department of Anesthesiology, University of Alabama at Birmingham. 
ï÷Associate Research Scientist, Department of Obstetrics and Gynecology. 
#Associate, Department of Anesthesia. 
**Professor, Department of Anesthesia. 
&dagger;&dagger;Associate Professor, Department of Anesthesia. 
Received from the University of Iowa College of Medicine, Iowa City, Iowa. Submitted for publication August 2, 1994. Accepted for publication October 6, 1994. Presented in part at the annual meeting of the Society for Obstetric Anesthesia and Perinatology, Philadelphia, Pennsylvania, May 14, 1994. Address correspondence to Dr. Vincent: Department of Anesthesia, University of Iowa College of Medicine, 200 Hawkins Drive, Iowa City,
Iowa 52242 [citas]
17. Comparison of haemodinamic changes in women with severe preeclampsia receiving combined spinal-epidural for labor analgesia vs cesarean. Ramanathan J. MD, Arunkumar V. MD. A. University of Tennessee, Memphis, Memphis, TN, USA. ASA Meeting Oct 1999. Obstet Gynecol 1998; 86:193-99.
Combined spinal-epidural anesthesia (CSE) can be safely used for cesarean delivery in women with severe preeclampsia (1). The purpose of our study was to compare maternal hemodynamic changes in preeclamptic women receiving CSE for labor analgesia (LA) with those receiving CSE for cesarean delivery (CS).
METHODS: The study was approved by the IRB. Of the 61 patients with severe preeclampsia (SBP>160 mm Hg, DBP >110 mm Hg or proteinuria 3+ or 4+), 30 delivered vaginally and 31 underwent CS. For labor analgesia (LA group, n=30), after hydration with 800 ml of plain LR, CSE was given with a mixture of 1.25 mg of plain bupivacaine (BUP) and 25 µg of fentanyl (fent) intrathecally followed by 0.0625% BUP with 4µg fent/ml epidurally at 12-15 ml /hr. In the CS group (n = 31), after hydration with1500 ml of LR, 7.5 mg of hyperbaric BUP with 25 µg of fent was given intrathecally and 2% lidocaine epidurally as needed to maintain > T4 block. Maternal SYST, DIAST, MAP and heart rate (HR) were recorded before and after CSE in both groups. Statistical analysis was performed using t-test, Chi-square analysis and p< 0.05 was considered significant
RESULTS: Baseline MAP was similar in two groups (114 +/-14 mm Hg in LA group vs.119 +/-13 mm Hg in CS group). After CSE, MAP decreased significantly in both groups (96 +/- 13 mm Hg in LA group vs. 100 +/-16 mm Hg in CS group p<0.01). There were no significant differences in MAP values after CSE between groups. In addition, the percent changes in MAP from baseline ( - 16 +/- 9% in LA group vs. -15 +/- 13% in CS group) were similar.
CONCLUSIONS: Our results indicate that MAP decreases significantly in preeclamptic women receiving CSE for CS or LA. However, despite the higher levels of sympathetic blockade in the CS group, the severity of hypotension associated with CSE in the CS group and LA group are quite similar [citas]
18. Complications with 25 G and 27 G Whitacre Needles during combined-spinal epidural analgesia in labor. Ruth Landau, MD; Christopher F Ciliberto, MD; Stephanie R Goodman, MD; Susan HK Kim-Lo, MD; Richard M Smiley, MD, PhD. Columbia University College of Physicians and Surgeons, New York, NY. ASA Meeting Oct 1999. Anesth Analg 86:520-522, 1998.
INTRODUCTION: We have noted a high incidence of paresthesias during placement of the spinal needle during a combined spinal-epidural (CSE) procedure. It has been reported that needle size may influence the incidence of paresthesia and other complications during CSE (1). We compared the occurrence of paresthesia and postdural puncture headache (PDPH) in parturients who received a CSE for labor analgesia with either a 25G or 27G Whitacre needle.
METHODS: With IRB approval, we performed a prospective observational study on the CSE procedure with kits containing either a 4 5/11" 25G Whitacre or 4 5/11" thin-walled "high flow" 27G Whitacre spinal needle (Becton Dickinson, Franklin Lakes, NJ). Data from 478 consecutive women receiving labor analgesia was gathered; in the first 199 subjects CSE was performed with the 25 G needle; in the remaining 279 subjects the 27G needle was used. We recorded the incidence of paresthesia upon spinal needle placement, the duration and character of any paresthesia, and the incidence and treatment of PDPH. Categorical data was analyzed by Chi-squared or Fisher's exact test (p<0.05).
RESULTS: The incidence of paresthesia was similar between the two needles (16%) (Table). Approximately one-fourth of the paresthesias were described as "electric" with no difference between groups. There was a higher incidence of PDPH in the 25G group (4% v 0.7%). Three patients in the 25G group received an epidural blood patch (EBP), versus 1 in the 27G group.
DISCUSSION: We confirmed the relatively high incidence (16%) of paresthesia during the CSE procedure. Our data suggest that with Whitacre needles, 27G needles might be preferable over 25G in reducing the rate of PDPH in parturients but do not alter the incidence of transient paresthesia [citas]
19. Patient selection bias contributes to an increased incidence of fetal bradycardia after combined spinal/epidural analgesia for labor. Edward T Riley, MD; Tracey M Vogel, MD; Yasser Y El-Sayed, MD; Paul M Meyer, MD; Sheila E Cohen, MB, ChB. Stanford University School of Medicine, Stanford, CA, U.S.A. ASA Meeting Oct 1999.
Labor analgesia with the combined spinal/epidural (CSE) technique has been associated with fetal bradycardia (FB) secondary to uterine hypertonus caused by decreased circulating catecholamines. In contrast to our clinical observations, recent studies have not demonstrated an increased incidence of FB with CSE vs. epidural analgesia (e.g. Anesth Analg 1996;83:742-7). To assess the significance of this problem in our practice, we collected a non-randomized, prospective database on 196 laboring women requesting analgesia. They received either an epidural (n=98) or CSE (n=98) block based on the clinical judgment of the attending anesthesiologist. CSE was often chosen for women in severe pain or in more advanced labor. Fetal monitoring strips were evaluated by an obstetrician blinded to technique. FB was defined as an acute decrease in FHR to <120 bpm lasting >2 min. Patients given the CSE technique were in more pain and had a greater cervical dilation prior to the block. They also had better pain relief (faster onset and less treatment for inadequate analgesia), more uterine hypertonus, a higher incidence of FB (17% vs 5%; P <0.05), more itching, and more hypotension compared to the epidural group. If pain relief and decreased circulating catecholamines lead to FB, then patients in greater pain may be more prone to have FB after analgesia, as was found in this study. Thus, patient selection bias, rather than the analgesic technique itself, most likely explains these results[citas]
20. Gravity flow epidural block versus combined spina epidural (CSE) for cesarean section. Is the addition of spinal anesthesia necessary?. S Cohen, MD; B Hronkova, MD; M Croitoru, MD; E Burley, BS; W. Urie, BS. UMDNJ-RWJUH, New Brunswick, NJ, USA. ASA Meeting Oct 1999. S. Cohen et al. Anesth Analg 86:5364, 1998.
INTRODUCTION: Epidural {1} admin. of local a. by gravity via the needle has been assoc. with a higher success rate than injection through the catheter. To determine if this gravity technique is assoc. with higher success rate than the CSE technique, we studied 106 consenting parturients who received neuroaxial (NA) block for C/S.
METHODS: The pt's were randomly allocated. GI (n=54) epidural solution by gravity into the needle before insertion of the catheter. GII (n=52) spinal solution via ESPOCAN 25g needle (B. Braun Medical Inc.) inserted through epidural needle before insertion of the catheter. GI pt's received 3, 5, 5, 5 & 3ml (total of 21ml) of 75%
ropivacaine (R) with 5mcg/ml epinephrine (E) & 5mcg/ml fentanyl (F). GII pt's received 10mg R with 100mcg E & 25mcg F intrathecally followed by catheter insertion.
RESULTS: Values are mean [SD]. Groups did not differ in age, height, parity, duration of surgery, incidence of itching, sedation, nausea, hypotension or APGAR scores. There were 11 pt's in GII & none in GI (p<0.0001) for whom NA block was unsuccessful (due to failure to pierce the dura). Time to incision was (41.9[9.6] & 35.6[6.9]) for GI & II respectively (p<0.0005). More pt's in GII had vomiting (13 vs. 7, p<0.04) & catheter paresthesia (23 vs. 12, p<0.004). 9 of 41 pt's in GII & 4 of 54 in GI the block alone did not provide satisf. analgesia (p<0.04).
CONCLUSION: These data show that gravity technique via the needle has a higher success rate, better quality of anesthesia, & fewer paresthesias than CSE technique for C/S [citas]
21. Dose and response of intrathecal sufentanil added to bupivacaine for labor analgesia.Cynthia A. Wong, MD; B. M. Scavone, MD; M. Loffredi, MD; J. N. Ganchiff, RN; W. Y. Wang, MD. Northwestern University Medical School, Chicago, IL, USA. ASA Meeting Oct 1999.
INTRODUCTION: Bupivacaine added to intrathecal (IT) sufentanil for labor analgesia improves the quality and duration of analgesia (Anesth Analg 81:305-9, 1995.) The purpose of this study was to determine the optimal dose of IT sufentanil added to bupivacaine 2.5 mg for CSE labor analgesia.
METHODS: Multiparous patients scheduled for induction of labor, with cervical dilation >3 and  5 cm, gave informed consent to participate in this IRB-approved, double-blind study. Patients were randomly assigned to receive sufentanil 0 (G1), 2.5 (G2), 5 (G3), 7.5 (G4) or 10 ug (G5) added to bupivacaine. A blinded nurse evaluated VAS and side-effects at 15 min intervals until the patient requested additional analgesia. Data were analyzed by Chi square, Fisher exact, ANOVA and Kruskal-Wallace tests. P < 0.05 was considered significant.
RESULTS: 169 patients participated. Groups were similar for age, height, weight, baseline VAS, and duration of labor. VAS was higher for G1 at all time periods, including the VAS at rebolus. Twelve G1, 2-G2, 3-G3, 0-G4 and 2-G5 patients had a VAS > 20 mm at 15 min. Duration of action was significantly shorter for G1 compared to G2-5 (39+/-25 vs 93+/-32, 93+/-47, 94+/-33, 100+/-37 min). Patients in G4-5 had more severe pruritus compared to G2-3. Significantly fewer patients in G1-4 had nausea and vomiting compared to G5.
CONCLUSIONS: IT bupivacaine without sufentanil did not provide satisfactory analgesia for multiparous patients with cervical dilation at 3-5 cm. Bupivacaine combined with sufentanil 2.5 ug provided analgesia comparable to higher doses with less severe pruritus, and a lower incidence of nausea and vomiting. The optimal dose of sufentanil combined with bupivacaine for CSE is 2.5 ug [citas]
22. Subsequent epidural injection of lidocaine extends rostral anesthetic level after intrathecal fentanyl but not bupivacaine with fentanyl. Dan Choi, MD; C Qiu, MD; R Weitzner, MD; H Westbrook, MD; A Malinow, MD. U of Maryland, Baltimore, MD, USA. ASA Meeting Oct 1999.
INTRODUCTION: In dosing a CSE, does epidural injection of local anesthetic produce unpredictable results in a patient with existing spinal anesthesia?
METHODS: 59 OB patients gave written informed consent to an IRB approved protocol. As part of their standardly performed CSE, patients were randomly assigned to receive a stadard volume of: fentanyl (25 mcg)-(F)- mixed with one of four doses of plain bupivacaine (B): 0 mg (FB0); 2.5 mg (FB2.5); 3.75 mg (FB3.75) ; or, 7.5 mg (FB7.5). Resultant levels of sensory anesthesia to pin and lower extremity motor block (mod. Bromage score 0 = none, 3=full) were recorded for 20 min. Then, 10 ml of 1.5% lidocaine/epi (L) were epidurally injected. Data were recorded for 20 min. more. Data were subjected to chi-square, ANOVA and Scheffe's post hoc analysis. * p<0.05 was significant.
RESULTS: All sensory levels and Bromage scores were biateral and equal. Change (20 min after spinal injection to 20 min after epidural) in elicited: Rostral (median) level of anesthesia:FB0 (T5-T2)*;FB2.5 (T2-T2); FB3.75 (T2-T2); FB7.5 (T2.5-T2). Bromage (median) scores: FB0(0-1)*;FB2.5(0-1)*;FB3.75(1.5-2); FB7.5(2.5-2).
CONCLUSIONS: These results suggest: 1) epidural L will extend intrathecal F- but not FB-induced sensory anesthesia; 2) epidural injection with up to 10 mL L after spinal anesthesia will not produce "high" levels or unwanted "intense" motor block; 3) any "dural puncture flux" of L is clinically insignificant [citas]
23. The incidence of pruritus during labor analgesia with intrathecal fentanyl and bupivacaine. The effect of  decreasing fentantyl dose.Regina Y. Fragneto, M.D.; Charles H. Moore, Ph.D.; Peter H. Pan, M.D.; Vernon H. Ross, M.D.; Leslie Reese, M.S. Medical College of Virginia of VCU, Richmond, VA, USA. ASA Meeting Oct 1999.
Intrathecal (IT) fentanyl + bupivacaine (bup) provides effective pain relief for labor but pruritus often occurs. This study was designed to determine if decreasing the dose of IT fentanyl could decrease the incidence of pruritus while providing satisfactory analgesia. IRB approval & written informed consent were obtained. 45 laboring women (15/group) were randomized in a double-blind fasion to receive IT bup 2.5 mg & fentanyl: 15 µg (Grp I); 25 µg (Gr pII); or 35 µg (Grp III). A CSE technique was performed. Duration of IT analgesia, VAS pain & pruritus scores, duration & onset of pruritus, & need for pruritus treatment were assessed. Parametric data were analyzed by ANOVA & Tukey's multiple comparison test. Nonparametric data were analyzed by chi square. P<0.05 was considered significant. The duration of analgesia in min (Grp I 106±29, Grp II 124±59, GrpIII 137 ± 36) & the number of patients requiring treatment for pruritus (Grp I 1/15, Gr pII 2/15, Grp III 3/15) were similar among groups. The number of patients experiencing no itching was significantly less (Grp I 5/15, GrpII 5/15, GrpIII 0/15 p=0.04) & the duration of pruritus in min was greater (Grp I 33±26, Grp II 33±28, GrpIII 68 ± 28 p=0.002) for GrpIII compared to Grps I & II. Fentanyl 35 µg is not recommended since the duration & incidence of pruritus is greater without any improvement in duration or quality of analgesia. The use of 15 µg fentanyl + bup might be preferable over 25 µg since the same effect is achieved with less drug [citas]
24. The effect of epidural clonidine added to sufentanil for labor pain management.Robert K. Parker, D.O.; Neil Roy Connelly, M.D.; Tanuja Mainkar, M.D.; Raja R Venkata, M.D.; Mervat El-Mansoury, M.D. Baystate Medical Center, Tufts School of Medicine, Springfield, MA, USA. ASA Meeting Oct 1999.
INTRODUCTION: It has been shown that the use of epidural sufentanil(S) following a dose of lidocaine(L) and epinephrine(E) provides similar analgesia compared to intrathecal S, although with a lower incidence of pruritis. Clonidine(C) has been added to intrathecal S to increase analgesic duration. We thus undertook this
study to determine whether epidural C would alter the duration of analgesia when given with epidural S.
METHODS: IRB approved. 40 primiparous pts, >32 weeks,<5cm cervical dilatation. Baseline VAS obtained, lumbar epidural placed, test dose of 3ml 1.5% L with E. Patients were given one of two injections: Group S: S 20 ug with NS 10 ml. Group SC: S 20 ug+ C 75 ug. with NS 10 ml, VAS and side effects were recorded 5,10,15,20,30 min, and every 30 min thereafter. Demographic data-ANOVA. Pain scores-Mann Whitney U. Significance p<0.05
RESULTS: No demographic difference between groups. The duration of analgesia was 153± 78 in S and 178± 55 in SC. Three patients in SC delivered comfortably without need for a redose, whereas none in S did so. The incidence of C section was not different (2 in S, 3 in SC).
DISCUSSION: We believe epidural S technique has advantages over CSE no added needle cost and avoiding an intentional dural puncture with concomitant headache risk. C added to epidural S does not significantly prolong the analgesic duration for the management of labor pain [citas]
25. Intrathecal ropivacaine 1.25 mg VS 2.5 mg for labor-analgesia. Comparison of maternal and fetal complications. JW Chiu, DEAA; JL Chong, MMed; TH Sia, MMed; PF White, PhD, MD; CC Loo, FRCA. KK Women & Childrens’ Hospital, Singapore and UT Southwestern Medical Center, Dallas, TX, USA. ASA Meeting Oct 1999.
INTRODUCTION: Ropivacaine may prove advantageous for labor analgesia because of its decreased propensity for cardiotoxicity and motor block. The effects of two different doses of intrathecal (IT) ropivacaine combined with sufentanil for labor analgesia were compared using a combined spinal-epidural (CSE) technique.
METHODS: Fifty consenting primiparous parturients in early labor received either 1.25 mg (Gp R1) or 2.5 mg (Gp R2) of IT ropivacaine in combination with sufentanil 5mcg according to an IRB-approved randomized double-blind trial. The differences in the duration and intensity of sensory blockade, incidence of maternal hypotension, motor block and side effects, as well as patient satisfaction were evaluated.
RESULTS: There was a significant increase in the incidence of hypotension (40% vs. 20%) and shivering (40% vs 20%) in Gp R2 compared to Gp R1 [p<0.05]. Fetal bradycardia (12% vs 0%) was also more common in Gp R2 (p<0.05). Visual analog pain and satisfaction scores, quality and duration (115 ± 54 min vs 143 ± 40 min for Gp R1 and R2 respectively, p=NS) of analgesia, incidence of motor block and level of sensory block were similar in both groups. However, spontaneous delivery rates were significantly higher in Gp R1 (48% vs. 28%, p<0.05)
CONCLUSION: When intrathecal ropivacaine is used with sufentanil 5 mcg for labor analgesia, a dose of 1.25 mg is recommended to minimize side effects[citas]
26. Labor analgesia from spinal neostigmine, sufentanil, bupivacaine and clonidine.R D’Angelo, MD; L Dean, MD; G Meister, MD; K Nelson, MD. Wake Forest University, Winston-Salem, NC, USA- ASA Meeting Oct 1999.
Since spinal clonidine and spinal neostigmine each enhance analgesia from spinal opioids and local anesthetics, this study was designed to assess the analgesic efficacy and side effects of spinal neostigmine combined with spinal sufentanil, bupivacaine, and clonidine. After IRB approval and informed consent, 30 nulliparous women in early labor requesting analgesia were randomized to receive a 2.5 ml hyperbaric solution of sufentanil 10 mcg, bupivacaine 2.5 mg, and clonidine 50 mcg, with and without neostigmine 10 mcg. A CSE technique was utilized with each patient in the lateral position. Sensory levels to pinprick, objective and subjective motor block, VAS pain, nausea, pruritus, sedation, oxygen saturation, and maternal hemodynamics were assessed until more analgesia was requested. Also, duration of analgesia, ephedrine use, and Apgar scores were recorded. Data were analyzed as indicated; P<0.05 was considered significant. Women administered neostigmine were significantly older than women in the control group (29+/-6 vs 25+/-4 yrs); otherwise, demographic variables were similar between groups. The duration of spinal analgesia was similar between groups (215+/-60 [control] vs 205 ± 62 [neostigmine]). Women administered neostigmine experienced significantly more severe nausea (53% vs 13%); otherwise, the incidence of side effects was similar between groups. Spinal neostigmine 10 mcg produces nausea without enhancing labor analgesia when combined with spinal sufentanil, bupivacaine, and
clonidine [citas]
27. Documenting Central nerve Blockade. Tong-Khee Tan, FRCA. Royal Infirmary, Glasgow, Scotland, UK. ASA Meeting Oct 1999.
INTRODUCTION: Central nerve blockade (CNB) has the potential to inflict morbidity and mortality. The litiginous climate requires anaesthetists to keep contamporaneous records. This preliminary study surveys type / quality of information recorded by anaesthetists performing CNB.
METHOD: 66 records of anaesthetics which involved CNB in a University Hospital were prospectively reviewed, with anaesthetists unaware of this study. Obstetric and Chronic Pain procedures were excluded.
RESULTS: 25.6% were subarachnoid block(SAB), 19.8% combined spinal-epidural block(CSE), 54.6% epidurals. 45.5% of these patients had surgery under CNB alone while 54.5% had CNB with general anaesthesia. Standard information (dedicated space on anaesthetic chart) for injection site, needle size and type, substance, volume and concentration of injectate, epidural catheter details were recorded in almost all charts reviewed. Additional information (AI) individual remarks recorded by anaesthetists like recording pre-operative explanation of procedure (39.4%), sensory level established (65%) and post-operative instructions re-CNB(56%) was less complete though 96% of records had notes on position of patient during block procedure and the presence/absence of flow of cerebro-spinal fluid and blood. 74% remarked on asepsis.
CONCLUSION: Pre-determined spaces on standard charts help improve information recording and may improve recording of vital information like those in AI. Further data gathering, disseminating this study findings and redesigning the anaesthetic chart will improve quality of information recording by anaesthetists[citas]