Spinal anesthesia using hyperbaric 0.75% versus hyperbaric 1% bupivacaine for cesarean section

Although 0.75% hyperbaric bupivacaine is commonly administered to provide spinal anesthesia for cesarean section in the United States, in some countries, only the 1% hyperbaric solution of spinal bupivacaine is available. The aim of this study was to compare 0.75% with 1% hyperbaric spinal bupivacaine for cesarean section. In this prospective study, 50 patients undergoing elective cesarean section were randomized to receive a spinal anesthetic with either 1.5 mL of 0.75% bupivacaine (n = 25) or 1.125 mL of 1% bupivacaine (n = 25). There were no statistically significant differences in patient demographics, time to onset of block, or intraoperative pain. All patients had a successful block for surgery. The time from injection of the spinal anesthetic to first request for pain medication in the postanesthesia care unit was longer in the women who received 0.75% bupivacaine (4.3 vs 3 h; P < 0.05). Six women (24%) who received 1% bupivacaine versus one woman (4%) who received 0.75% bupivacaine complained of postoperative backache (P < 0.05). In addition, postdural puncture headache occurred in four women, all of whom received 1% bupivacaine (P = 0.04). In conclusion, our data suggest that 0.75% bupivacaine results in fewer postoperative problems and offers several significant benefits compared with the 1% concentration. IMPLICATIONS: Although 0.75% bupivacaine is usually used to provide spinal anesthesia for cesarean section in the United States, a more concentrated solution is popular in Europe. In this study, we compared 0.75% bupivacaine with 1% bupivacaine when administered for cesarean section and found that the 0.75% solution offers several significant benefits.     

Pharmacology of local anesthetics and clinical aspects of segmental blocking. II. Spinal anesthesia

Clinical picture of development of segmental blocking after subarachnoidal injection of hyperbaric solutions of 0.75% bupivacaine, 5% ultracaine, and isobaric 0.5% bupivacaine is studied. A total of 152 patients operated on the lower part of the body and the lower limbs were examined under conditions of single, prolonged subarachnoidal, and combined spinal epidural anesthesia. Ultracaine and bupivacaine in different concentrations with different barism provided anesthesia equivalent by the efficacy, depth, and dissemination of sensory block. Segmental blocking with 5% ultracaine was characterized by the shortest latent period (3.14 +/- 0.16 min, p < 0.05) but was no shorter (124.1 +/- 3.37 min) than operative analgesia with 0.75% hyperbaric bupivacaine (120.0 +/- 5.10 min). Isobaric bupivacaine provided the longest effective analgesia (215.0 +/- 45.0 min, p < 0.05). Microcatheter technique improved the safety and control of subarachnoidal anesthesia in comparison with a single injection, and combined spinal epidural anesthesia shortened the latent period of segmental blocking and ensured intraoperative anesthesia and postoperative analgesia at the expense of the epidural component.     

CSE vs. augmented epidural anesthesia for cesarean section. Spinal and epidural anesthesia with bupivacaine 0.5% "isobar" require augmentation

Incomplete anaesthesia is a major clinical problem both in single spinal and in single epidural anaesthesia. The clinical efficacy of epidural anaesthesia with augmentation (aEA) and combined epidural and spinal anesthesia (CSE) for cesarean section was investigated in a prospective randomized study on 45 patients. METHODS: Anaesthesia extending up to Th5 was aimed for. Depending on the patient's height, epidural anaesthesia was administered with a dose of 18-22 ml 0.5% bupivacaine and spinal anaesthesia with a dose of 11-15 mg 0.5% bupivacaine. Augmentation was carried out in all cases in epidural anaesthesia, initially with 7.5 ml 1% Lidocaine with epinephrine 1:400,000, raised by 1.5 ml per missing segment. The epidural reinjection in CSE was carried out as necessary with 9.5-15 ml 1% lidocaine with epinephrine, depending on the height and difference from the segment Th5. RESULTS: The extension of anaesthesia achieved in epidural anaesthesia after an initial dose of 101.8 mg bupivacaine and augmenting dose of 99 mg lidocaine reached the segment Th5. The primary spinal anaesthesia dose up to 15 mg corresponding to height led to a segmental extension to a maximum of Th3 under CSE. Augmentation was necessary in 13 patients; in 5 cases because of inadequate extent of anaesthesia and 8 cases because of pain resulting from premature reversion. The augmenting dose required was 13.9 ml. Readiness for operation was attained after 19.8 min (aEA) and after 10.5 min (CSE). No patient required analgesics before delivery. The additional analgesic requirement during operation was 63.6% (aEA) and 39.1% (CSE). Taking into account pain in the area of surgery, the requirement of analgesics was 50% (aEA) vs. 17.4% (CSE). Antiemetics were required in 18.2 (aEA) and in 65.2% (CSE). The systolic blood pressure fell by 17.7% (aEA) and in 30.3% (CSE). The minimum systolic pressure was observed after 13.4 min in aEA, and after 9.5 min in CSE. The APGAR score and the umbilical pH did not show any differences. General anaesthesia was not required in any case.     

Determination of an effective dose of intrathecal morphine for pain relief after cesarean delivery

Very small doses of intrathecal (i.t.) morphine (25-200 microg) have been used in an effort to provide effective postoperative pain relief while minimizing side effects after cesarean delivery. We performed a double-blinded study in 40 patients presenting for elective cesarean delivery in which i.t. morphine was administered along with oral hydrocodone/acetaminophen and other medications commonly administered after cesarean delivery. We administered i.t. morphine by up-down sequential allocation of doses. For the purposes of this study, adequate postoperative analgesia was defined as comfort not requiring i.v. morphine for 12 h after spinal anesthesia with bupivacaine, fentanyl, and morphine. In addition, a time and cost comparison was performed for study patients receiving intrathecal morphine compared with a historical group of patients receiving patient-controlled analgesia with i.v. morphine. We were unable to determine with meaningful precision a dose of i.t. morphine to provide analgesia in this context. However, very small doses of i.t. morphine combined with oral hydrocodone/acetaminophen and other medications commonly prescribed after cesarean delivery provided postoperative pain relief with no more time commitment than patient-controlled analgesia (148 +/- 61 vs 150 +/- 57 min) and with significantly less acquisition cost ($15.13 +/- $4.40 vs $34.64 +/- $15.55). Implications: When used along with oral analgesics, very small doses of spinal morphine provide adequate pain relief after cesarean delivery. Spinal anesthetics, oral analgesics, and other medications commonly prescribed to treat side effects after cesarean delivery contribute significantly to this analgesia. When small doses of spinal morphine are used in this setting, they provide adequate analgesia and patient satisfaction that is time- and cost-effective.     

Epidural anesthesia impairs both central and peripheral thermoregulatory control during general anesthesia

BACKGROUND: The authors tested the hypotheses that: (1) the vasoconstriction threshold during combined epidural/general anesthesia is less than that during general anesthesia alone; and (2) after vasoconstriction, core cooling rates during combined epidural/general anesthesia are greater than those during general anesthesia alone. Vasoconstriction thresholds and heat balance were evaluated under controlled circumstances in volunteers, whereas the clinical importance of intraoperative thermoregulatory vasoconstriction was evaluated in patients. METHODS: Five volunteers were each evaluated twice. On one of the randomly ordered days, epidural anesthesia (approximately T9 dermatomal level) was induced and maintained with 2-chloroprocaine. On both study days, general anesthesia was induced and maintained with isoflurane (0.7% end-tidal concentration), and core hypothermia was induced by surface cooling and continued for at least 1 h after fingertip vasoconstriction was observed. Patients undergoing colorectal surgery were randomly assigned to combined epidural/enflurane anesthesia (n = 13) or enflurane alone (n = 13). In appropriate patients, epidural anesthesia was maintained by an infusion of bupivacaine. The core temperature that triggered fingertip vasoconstriction identified the threshold. RESULTS: In the volunteers, the vasoconstriction threshold was 36.0 +/- 0.2 degrees C during isoflurane anesthesia alone, but significantly less, 35.1 +/- 0.7 degrees C, during combined epidural/isoflurane anesthesia. Cutaneous heat loss and the rates of core cooling were similar 30 min before vasoconstriction with and without epidural anesthesia. In the 30 min after vasoconstriction, heat loss decreased 33 +/- 13 W when the volunteers were given isoflurane alone, but only 8 +/- 16 W during combined epidural/isoflurane anesthesia. Similarly, the core cooling rates in the 30 min after vasoconstriction were significantly greater during combined epidural/isoflurane anesthesia (0.8 +/- 0.2 degrees C/h) than during isoflurane alone (0.2 +/- 0.1 degrees C/h). In the patients, end-tidal enflurane concentrations were slightly, but significantly, less in the patients given combined epidural/enflurane anesthesia (0.6 +/- 0.2% vs. 0.8 +/- 0.2%). Nonetheless, the vasoconstriction threshold was 34.5 +/- 0.6 degrees C in the epidural/enflurane group, which was significantly less than that in the other patients, 35.6 +/- 0.8 degrees C. When the study ended after 3 h of anesthesia, patients given combined epidural/enflurane anesthesia were 1.2 degrees C more hypothermic than those given general anesthesia alone. The rate of core cooling during the last hour of the study was 0.4 +/- 0.2 degrees C/h during combined epidural/enflurane anesthesia, but only 0.1 +/- 0.3 degrees C/h during enflurane alone. CONCLUSIONS: These data indicate that epidural anesthesia reduces the vasoconstriction threshold during general anesthesia. Furthermore, the markedly reduced rate of core cooling during general anesthesia alone illustrates the importance of leg vasoconstriction in maintaining core temperature.     

Evaluation of intravenous tenoxicam for postoperative cesarean delivery pain relief. Preliminary report

BACKGROUND AND OBJECTIVES: To assess safety and efficacy of tenoxicam for postoperative pain relief after cesarean delivery. METHODS: Postoperative pain relief, supplemental analgesic requirements, and adverse side effects were evaluated in 80 patients undergoing cesarean delivery. Forty patients received a slow intravenous injection of tenoxicam at a fixed dose of 20 mg (2 mL), immediately before induction of spinal anesthesia with 15 mg (3 mL) of 0.5% hyperbaric bupivacaine. The other 40 patients received 2 mL of saline solution. Newborns were evaluated by means of Apgar score and umbilical cord blood gases. RESULTS: There was a significant prolongation of analgesia in the tenoxicam group (365 +/- 91.1 minutes versus 305 +/- 53.2 minutes in control group, P < .001). Supplementary analgesic requirements were significantly decreased by intravenous tenoxicam (1.55 +/- 0.70 versus 2.25 +/- 0.68). Adverse side effects did not differ between groups and few complaints of phlebitis were noted. Apgar scores and blood gas analyses were similar in neonates from both groups. CONCLUSIONS: Intravenous tenoxicam is safe and slightly increases the length of postoperative analgesia provided by the local anesthetic. It is effective in decreasing analgesic consumption in cesarean delivery patients.     

Intraoperative intravenous ketamine in combination with epidural analgesia: postoperative analgesia after renal surgery

We designed this double-blinded, randomized, controlled study to evaluate the effect of small-dose ketamine IV in combination with epidural morphine and bupivacaine on postoperative pain after renal surgery. An epidural catheter was inserted, and the administration of morphine and bupivacaine was started before surgery. Forty patients were assigned to one of two groups (ketamine or control). The ketamine group was administered a ketamine bolus and infusion during surgery. The median visual analog pain scale (VAS) scores at rest were significantly lower in the ketamine group during the first 6 h (P < 0.01). VAS pain scores on coughing were also significantly lower in the ketamine group (P < 0.01). Cumulative postoperative total analgesic consumption was less in the ketamine group on Days 1 and 2 (P < 0.001). The first analgesic demand time was shorter in the control group (9.2 +/- 11.5 min) than in the ketamine group (22.3 +/- 17.1 min) (P < 0.0001). The incidence of nausea and pruritus was more frequent in the control group (P < 0.05). In conclusion, postoperative analgesia was more effective when spinal cord and brain sensitization were blocked by a combination of epidural morphine/bupivacaine and IV ketamine. IMPLICATIONS: Renal nociception conducted multisegmentally by both the spinal nerves (T10 to L1) and the vagus nerve cannot be blocked by epidural analgesia alone. We demonstrated that IV ketamine had an improved analgesic or opioid-sparing effect when it was combined with epidural bupivacaine and morphine after renal surgery.     

Postoperative patient-controlled epidural analgesia with opioid bupivacaine mixtures

PURPOSE: To determine the efficacy and safety of patient-controlled epidural analgesia of morphine or fentanyl in combination with bupivacaine for postoperative pain relief. METHODS: Forty ASA I-II patients scheduled for major abdominal surgery were studied. After insertion of a lumbar epidural catheter, patients were given a non-opioid general anaesthetic. After surgery patients complaining of pain, received a loading dose of 2 mg morphine (Group I) or 50 micrograms fentanyl (Group II). For continuing pain, 1 mg morphine in 4 ml bupivacaine 0.125% (0.25 mg.ml-1 morphine and 1 mg.ml-1 bupivacaine, Group I) or 20 micrograms fentanyl in 4 ml bupivacaine 0.125% (5 micrograms.ml-1 fentanyl and 1 mg.ml-1 bupivacaine Group II) were administered. Blood pressure, heart rate, respiratory rate and SpO2 were monitored. Assessments of pain (VAS), nausea-vomiting, motor block, pruritus and sedation were recorded for 24 hr. RESULTS: No difference in pain or sedation was observed between groups. The 24 hr postoperative opioid consumption was 15.50 +/- 7.53 mg morphine and 555.10 +/- 183.85 micrograms fentanyl. Total bupivacaine 0.125% consumption was 58.00 +/- 30.14 ml in Group I and 101.05 +/- 36.77 ml in Group II. One patient in Group II complained of motor weakness in one leg. The incidence of nausea (Group I 45%, Group II 10% P < 0.05) and pruritus (Group I 30%, Group II 5% P < 0.05) was less in patients receiving fentanyl. CONCLUSION: Both methods were effective in the prevention of pain but, because of fewer side effects, fentanyl may be preferable to morphine.     

Higher rate of fetal acidemia after regional anesthesia for elective cesarean delivery

OBJECTIVE: To determine the prevalence of fetal acidemia associated with regional anesthesia for elective cesarean delivery in healthy paturients with uncomplicated singleton term pregnancies. METHODS: This was an epidemiologic study using the data base of the Swiss obstetric study group (Arbeitsgemeinschaft Schweizerischer Frauenkliniken). After the exclusion of cases with extraneous factors that may have affected the health of the neonate, we analyzed the umbilical artery pH, Apgar score, and other neonatal outcome measures after cesarean delivery with reference to the anesthetic technique. RESULTS: From 1985 to 1994, 327,763 deliveries, including 40,858 (12.47%) by cesarean, were registered in the data base. Of these, 5806 patients fulfilled the study criteria. The study population included 1002 spinal, 2155 epidural, and 2649 cases of general anesthesia. The frequency of fetal acidemia (pH less than 7.10) was significantly increased in the spinal-anesthesia group (odds ratio [OR] 4.67; 95% confidence interval [CI] 2.73, 8.01) and in the epidural group (OR 2.39; 95% CI 1.42, 4.04) compared with the general-anesthesia group. CONCLUSION: The rate of fetal acidemia is significantly increased after regional anesthesia. This risk must be judged in light of the risks inherent with general anesthesia.     

Small-dose hyperbaric versus plain bupivacaine during spinal anesthesia for cesarean section

In a double-blind, randomized trial, 98 parturients undergoing cesarean section received either hyperbaric or plain bupivacaine 6.6 mg combined with sufentanil 3.3 microg as part of a combined spinal-epidural procedure. To prevent hypotension, 1000 mL of lactated Ringer's solution, 500 mL of hydroxyethyl starch 6%, and ephedrine 5 mg were administered i.v. The height of the block was equal in both groups, but more patients in the plain group had blocks that were either too high or too low (P < 0.01). The number of patients requiring epidural supplementation was equal in both groups. Strict criteria were used to treat hypotension. The overall incidence of systolic blood pressure (<90 mm Hg) was 13%, whereas it was more pronounced in the plain group (21% vs 6% in the hyperbaric group, P < 0.05), which required more ephedrine (P < 0.05) and in which a greater incidence of nausea was noticed (P < 0.05). We conclude that the use of a small dose of intrathecal bupivacaine combined with sufentanil plus our described preloading regimen resulted in a lower incidence of hypotension. Further, we conclude that the use of hyperbaric bupivacaine in this manner provides a more reliable block and a lower incidence of hypotension than plain bupivacaine. Implications: A small dose of hyperbaric bupivacaine 0.5% combined with sufentanil used intrathecally during cesarean section offered a more reliable cephalad spread of the spinal block than the glucose-free combination, which was reflected in a lower incidence of hypotension and nausea.     

Current local anesthetics in segmental nerve blocks

The evolution of central segmental blockades was studied in 133 patients by using epidural and spinal anesthesias. The efficiencies of 2% Ultracaine (Hoechst) and 2% Lidocaine (Egis) solutions used for epidural anesthesia and 5% Ultracaine (Hoechst) and 0.75% Bupivacaine (Astra) hyperbaric solutions were evaluated. Central segmental blockade induced by Ultracaine was found to be similar to Lidocaine and Bupivacaine in clinical parameters. At epidural blockade, the latent period was identical for the two agents and the duration of analgesia caused by Ultracaine was 20 minutes longer than that with Lidocaine, the consumption of the former being 20% less. At spinal anesthesia, there were no great differences in the depth and duration of conduction block, but with 5% Ultracaine, the analgesic zone was large (13.2 +/- 1.0 and 15.1 +/- 0.6 segments, p < 0.05). No differences were found in the magnitude of hemodynamic changes both with various anesthetics and different types of segmental blockades. The findings make it possible to regard Ultracaine as an drug that has some advantage over Lidocaine for prolonged epidural anesthesia and similar to the latter in pharmacological characteristics. Ultracaine may be regarded as alternative to Bupivacaine for spinal anesthesia.     

Reattempting failed external cephalic version under epidural anesthesia

OBJECTIVES: We hypothesize that the success rate of external cephalic version may be increased by performing a repeat attempt with the patient under epidural anesthesia. STUDY DESIGN: One hundred eight women with term singleton pregnancies in breech presentation underwent attempted external version. When external version failed, we offered them the option of a later attempt under epidural anesthesia. All fetuses who remained in breech position were delivered by elective cesarean section. RESULTS: Fifty (60%) of the 83 attempted external versions performed without anesthesia were successful. Seventeen of the 33 women whose versions were unsuccessful underwent elective cesarean delivery, and 16 elected to undergo repeat version attempts under epidural. Nine (56%) of these 16 procedures were successful, and 7 of these 9 women were delivered vaginally. The overall success rate was 71%, similar to the success rate of versions attempted on 25 women under epidural anesthesia. CONCLUSIONS: When an attempted external version fails, a repeat attempt under epidural anesthesia will usually be successful, resulting in a lower cesarean delivery rate.     

Combined spinal and epidural anesthesia for cesarean section in a parturient with moyamoya disease

We present the case of a parturient with moyamoya disease admitted to the hospital for elective cesarean section. Combined spinal and epidural technique was chosen because it allows better analgesia than epidural anesthesia and more hemodynamic stability than either general or spinal anesthesia. Ropivacaine was the local anesthetic of choice for the epidural portion because of the wide sensory-motor dissociation, thus preserving adequate respiration in the case of a high block.     

Intrathecal fentanyl with small-dose dilute bupivacaine: better anesthesia without prolonging recovery

Recent concern regarding lidocaine neurotoxicity has prompted efforts to find alternatives to lidocaine spinal anesthesia. Small-dose dilute bupivacaine spinal anesthesia yields a comparably rapid recovery profile but may provide insufficient anesthesia. By exploiting the synergism between intrathecal opioids and local anesthetics, it may be possible to augment the spinal anesthesia without prolonging recovery. Fifty patients undergoing ambulatory surgical arthroscopy were randomized into two groups receiving spinal anesthesia with 3 ml 0.17% bupivacaine in 2.66% dextrose without (Group I) or with (Group II) the addition of 10 microg fentanyl. Median block levels reached T7 and T8, respectively (P = not significant [NS]). Mean times to two-segment regression, S2 regression, time out of bed, time to urination, and time to discharge were 53 vs 67 min (P < 0.01), 120 vs 146 min (P < 0.05), 146 vs 163 min (P = NS), 169 vs 177 min (P = NS), and 187 vs 195 min (P = NS) respectively. Motor blockade was similar between groups, but sensory blockade was significantly more intense in Group II (P < 0.01). Six of 25 blocks failed in Group I, whereas none failed in Group II. The addition of 10 microg fentanyl to spinal anesthesia with dilute small-dose bupivacaine intensifies and increases the duration of sensory blockade without increasing the intensity of motor blockade or prolonging recovery to micturition or street fitness. IMPLICATIONS: Concerns about the neurotoxicity of lidocaine have prompted efforts to find alternatives to lidocaine spinal anesthesia. We studied 50 patients undergoing ambulatory surgical arthroscopy and found that although small-dose bupivacaine alone is inadequate for this procedure, the addition of fentanyl makes it reliable.     

The efficacy of epinephrine test doses during spinal anesthesia in volunteers: implications for combined spinal-epidural anesthesia

Epinephrine test doses may be administered during combined spinal-epidural anesthesia to determine intravascular placement of epidural catheters. This study was designed to determine systolic blood pressure (SBP) and heart rate (HR) responses to intravenous injection of epinephrine (15 microg) during spinal anesthesia. Twelve volunteers received three spinal anesthetics (lidocaine 100 mg, tetracaine 15 mg, and bupivacaine 15 mg) in a randomized, double blind, cross-over fashion. Epinephrine was administered prior to spinal anesthesia (control), 30 min after injection of spinal anesthesia, and at regression of sensory block to T-10. SBP was measured with a radial arterial catheter and HR with an electrocardiogram. Positive responses were defined as peak increase in SBP > or = 15 mm Hg or HR > or = 20 bpm after injection of epinephrine. Compared with control, peak SBP responses decreased by a mean of 12 mm Hg during spinal anesthesia with tetracaine and bupivacaine (P < 0.05). Peak HR responses decreased by 11 bpm during all three spinal anesthetics (P < 0.05). Incidences of detection of intravenous injection by positive SBP and HR responses ranged from 50% to 100% and were not significantly affected by spinal anesthesia. Spinal anesthesia reduces hemodynamic responses to intravenous epinephrine injection but is unlikely to reduce detection by positive SBP and HR criteria.     

Epidural fentanyl produces labor analgesia by a spinal mechanism

BACKGROUND: The purpose of this study was to determine if epidural fentanyl produces analgesia in laboring patients by a primary spinal or supraspinal action. METHODS: Fifty-four parturients were randomized to receive epidural 0.125% bupivacaine plus one of three treatments: epidural saline-intravenous saline, epidural fentanyl (20 microg/h)-intravenous saline, or epidural saline-intravenous fentanyl (20 microg/h). The study treatments were administered by continuous infusion, whereas epidural bupivacaine use was patient controlled. RESULTS: Epidural bupivacaine use was significantly reduced by epidural (11.5+/-4.6 ml/h) but not by intravenous fentanyl (15.9+/-4.5 ml/h) compared with saline control (16+/-5.9 ml/ h). Analgesia characteristics and side effects were similar among groups. CONCLUSIONS: Low-dose epidural infusions of fentanyl produce labor analgesia by a primary spinal action.     

Effect of epidural vs parenteral opioid analgesia on the progress of labor: a meta-analysis

CONTEXT: Epidural labor analgesia, if selected by the patient, is associated with high cesarean delivery rates. Results of randomized trials comparing rates of cesarean delivery using epidural anesthesia vs parenteral opioids are inconsistent. OBJECTIVE: To review the effects of epidural vs parenteral opioid analgesia on cesarean delivery rates. DATA SOURCES: Studies were identified by searching MEDLINE from January 1966 through January 1998, the Cochrane Database of Perinatal Trials, and relevant nonindexed journals and abstracts. STUDY SELECTION: We included all studies that randomized patients to epidural vs parenteral opioid labor analgesia. DATA EXTRACTION: Two authors independently extracted data from 10 trials enrolling 2369 patients. Odds ratios (ORs) for categorical data, weighted mean differences (WMDs) for continuous data, and 95% confidence intervals (CIs) were calculated using a random-effects model. DATA SYNTHESIS: The risk of cesarean delivery did not differ between patients receiving epidural (8.2%) vs parenteral opioid (5.6%) analgesia (OR, 1.5; 95% CI, 0.81-2.76). Epidural patients had longer first (WMD, 42 minutes; 95% CI, 17-68 minutes) and second (WMD, 14 minutes; 95% CI, 5-23 minutes) labor stages. While epidural patients were more likely to have instrumented delivery (OR, 2.19; 95% CI, 1.32-7.78), they were no more likely to have instrumented delivery for dystocia (OR, 0.68; 95% CI, 0.31-1.49). After epidural analgesia, neonates were less likely to have low 5-minute Apgar scores (OR, 0.38; 95% CI, 0.18-0.81) or to need naloxone (OR, 0.24; 95% CI, 0.07-0.77). Women receiving epidural analgesia had lower pain scores during the first (WMD, -40 mm on a 100-mm scale; 95% CI, -42 to -38 mm) and second (WMD, -29 mm; 95% CI, -38 to -21 mm) stages of labor. The odds of dissatisfaction were lower with epidural analgesia (OR, 0.25; 95% CI, 0.20-0.32). CONCLUSIONS: Epidural labor analgesia is not associated with increased rates of instrumented vaginal delivery for dystocia or cesarean delivery. Patients receiving epidural analgesia have longer labors. Patient satisfaction and neonatal outcome are better after epidural than parenteral opioid analgesia.     

Treatment of human pulmonary paragonimiasis with triclabendazole: clinical tolerance and drug efficacy

We report the anesthetic management of a patient with aortitis syndrome using combined spinal and epidural anesthesia. A 28-year-old gravida with aortitis syndrome accompanied by faints was scheduled for an urgent cesarean section. Combined spinal and epidural anesthesia was thought to be better for this case in order to monitor the cerebral circulation by her consciousness level and to reduce the hemodynamic change during surgery as compared to spinal or epidural anesthesia alone. After inserting an epidural catheter at the Th 12/L 1 interspace, spinal anesthesia was performed with 1.5 ml of 0.3% dibucaine at the L 4/L 5 interspace. The level of analgesia was under L 1 with the pinprick method 10 min after the spinal anesthesia. Next, 5 ml of 1.5% mepivacaine was injected through the epidural catheter. The level of analgesia reached to Th 6 without major hemodynamic changes. A healthy 2740 g infant was delivered and she had an uneventful recovery. We conclude that combined spinal and epidural anesthesia is useful in a patient with aortitis syndrome undergoing an urgent cesarean section in order to monitor the cerebral circulation by the consciousness level and to reduce the hemodynamic change.     

Epidural anesthesia for a patient with Charcot-Marie-Tooth disease, mitral valve prolapse syndrome and IInd degree AV block

A 24-year-old, 48 kg female with Charcot-Marie-Tooth disease, mitral valve prolapse syndrome and IInd degree AV block was scheduled for emergency cesarean section under epidural anesthesia. This anesthesia was chosen because she had heart disease. Furthermore, the combination of general anesthesia with neuromuscular blockade posed the risk of a prolonged response to muscle relaxants and resulting respiratory insufficiency. Surgery lasted 50 min and proceeded uneventfully. A normal female infant was delivered with Apgar scores of 9 at 1 min and 10 at 5 min. Epidural anesthesia was safely performed during the operation. Postoperatively, there were no signs of respiratory or neurologic dysfunction. In conclusion, epidural anesthesia seems to be a good choice for a patient with Charcot-Marie-Tooth disease.     

The effects of general versus epidural anesthesia for outpatient extracorporeal shock wave lithotripsy

Although many anesthetic techniques are described for immersion extracorporeal shock wave lithotripsy (ESWL), regional and i.v. techniques are the most commonly reported. This randomized, prospective study compared general anesthesia (GA) and epidural anesthesia (EPID) with regard to effectiveness, side effects, induction time, and recovery in patients undergoing ESWL using an unmodified Dornier HM-3 lithotriptor. Twenty-six healthy outpatients were randomized to GA (propofol, N2O, laryngeal mask airway) or EPID (lidocaine 1.5% with epinephrine). Intraoperative and postoperative supplemental medications, side effects, and complications were noted. Induction times and times required to meet standard recovery criteria were compared between groups. Patients were surveyed regarding their satisfaction with anesthesia. All patients in the EPID group had effective blocks with a single catheter insertion and local anesthetic injection. In the GA group, the LMA was inserted successfully in all patients. Time from room entry to procedure start was significantly less in the GA group (23 +/- 11 vs 34 +/- 9 min; P < 0.05). Patients in the GA group were ready for discharge home earlier (127 +/- 59 vs 178 +/- 49 min; P < 0.05). Only three patients experienced nausea (one in the GA group, two in the EPID group). There were no differences in patient or urologist satisfaction with anesthesia. We conclude that GA is associated with a rapid recovery compared with EPID. Implications: General anesthesia with propofol, nitrous oxide, and a laryngeal mask airway is comparable to epidural anesthesia with lidocaine for outpatient extracorporeal shock wave lithotripsy procedures. However, early recovery is more rapid after general anesthesia compared with epidural anesthesia.