Continuous extradural infusion of ropivacaine 2 mg ml-1 for pain relief during labour

We have assessed the dose-response relationship of a solution of ropivacaine 2 mg ml-1, given as a continuous extradural infusion to women in labour. A total of 133 parturients were allocated randomly to one of four groups to receive a fixed rate ropivacaine infusion of 4, 6, 8 or 10 ml h-1 with additional bolus doses as necessary. Contraction pain, quality of analgesia, sensory block, motor block and neonatal Apgar scores were assessed. There were no significant differences between groups in terms of analgesia or motor block, although significantly more bolus doses were required by the group receiving 4 ml h-1 (P < 0.05 compared with the other groups), and a significantly higher total dose of ropivacaine was administered to the 10-ml h-1 group compared with the 6-ml h-1 group (P = 0.044). There were no significant differences between groups in terms of obstetric or neonatal outcome. We conclude that ropivacaine 2 mg ml-1 was effective and well tolerated when given as a continuous extradural infusion at 6-8 ml h-1 and may be used as the sole analgesic during labour.     

Obstetricians'' knowledge and attitudes toward epidural analgesia in labour

A 30 kDa immunodominant surface antigen (p30) of Babesia equi has been used as a diagnostic antigen. The B cell epitopes on this molecule recognized by horse sera and monoclonal antibody (MAb) against p30, 36/133.97, were determined. A synthetic peptide of p30 with amino acid sequence of 123FYQEVLFKGFEAV135 exhibited strong positive reaction with the infected horse sera. In contrast, MAb 36/133.97 recognized different region of p30, as peptide synthesized with amino acid sequence of 27ASGAVVDFQLESI39 reacted strongly. In competitive inhibition ELISA, the binding of MAb 36/133.97 to recombinant p30 was inhibited by horse antibodies, although they did not recognize same or an overlapping epitope. The data on B cell epitopes in this study may be important in improving serodiagnostic methods of B. equi infection.     

Epidural analgesia for labour and delivery: informed consent issues

We analyzed the clade distribution of B and E in HIV-1 isolates in Japan by a nested PCR method using 5'-CCCACAAGATTTAAATATG-3' of the gag gene as clade B primer and 5'-CCCACAAGATTTAAACTCC-3' of the gag gene as clade E primer. Seventy-two anti-HIV-1 confirmatory positive serum samples were collected during a period of 1991-1996 in two hospitals in Yokohama City. Peripheral blood mononuclear cells were obtained from the buffy coat of these samples and extracted DNA were used for nested PCR. The 72 cases comprised of 11 Japanese hemophiliacs, 14 Japanese male homosexuals, 19 Japanese male heterosexuals, 5 Japanese female heterosexuals and 23 Thai female heterosexuals. Of these 36 were clade B and 35 were clade E and one case showed positive PCR results for both B and E primers. Almost all male Japanese hemophiliacs and homosexuals in our sample have clade B, while the female Thai heterosexuals have clade E, irrespective of the year of isolation. As for Japanese male heterosexuals, through 1993, clade B was predominant but since 1994, the predominate clade switched to clade E. Although the number of Japanese female heterosexuals in our sample is small, clade B was isolated in 2 cases even after 1994.     

Back pain following epidural anaesthesia in labour

For palliative therapy of Duchenne muscular dystrophy (DMD), corticosteroids have been tried since 1970. According to recent reports, corticosteroids maintained muscular strength to some extent and prolonged period of ambulation. However, their mechanism of action is mostly unclear. In the present study, mdx mice were injected with 0.6 mg prednisolone 3 times a week for 30 weeks. Serum creatine kinase (CK) values remained 23% of controls. In muscle pathology of the quadriceps muscle, fibers with peripheral nuclei were increased, suggesting reduction of muscle necrosis. In pathological examination of liver, pyknotic cytoplasmic masses and formation of vacuoles were observed. Present study showed that prednisolone might attenuate muscle fiber necrosis at least for 30 weeks. Prednisolone may reduce secondary tissue reactions, which develop more serious muscle damage.     

Intrathecal sufentanil compared with epidural bupivacaine analgesia in labour

Epidural analgesia for pain relief during labour has certain disadvantages including slow onset. However, intrathecal sufentanil provides rapid onset and well-controlled analgesia lasting 1-4 h. The aim of this study was to compare the analgesia and the side effects of intrathecal sufentanil with epidural bupivacaine during labour. In a randomized, double-blind and controlled trial 58 parturient women requesting analgesia during labour were studied. The patients received either intrathecal sufentanil 10 micrograms and epidural saline, or intrathecal saline and epidural bupivacaine 20 mg. Visual analogue scores (VAS) for pain, blood pressure, heart rate, respiratory rate, level of sedation and the incidence of pruritus and nausea were recorded. Pain scores were significantly lower between 5 and 90 min after injection in patients receiving intrathecal sufentanil. Pruritus was significantly more frequent among those receiving intrathecal sufentanil. The rapid onset and effective analgesia of intrathecal sufentanil may in certain situations be advantageous.     

Regional analgesia in early active labour: combined spinal epidural vs. epidural

Conventional calculation of joint power is not effective in order to assess translational motions of human body. Two new approaches were developed in this study to estimate translational mechanical outputs from individual joints. They were applied to the analysis of vertical jump motions of six male subjects. In both cases, body of subjects were modeled with a four mass-points system model, and joints were regarded as motion generators. In one approach, increase of vertical component of ground reaction force (GRF) was decomposed into push-off force of three joints (ankle, knee, and hip joints). This procedure gave an estimation of impulse exerted per leg, as 83-92 N s (95% confidential interval) for squat jump, which was similar to half of the impulse provided to mass center of the body calculated from GRF, 82-88 N s. In the other approach, amount of the power exerted by each joint vertically was estimated by calculating the scalar product of joint reaction force and relative velocity vectors of adjacent segments. This approach gave estimation of vertical work provision per leg, as 201-226 and 141-181 J for squat and counter movement jumps, which were not so different from half of the work provided to mass center of the body calculated from GRF, 209-227 and 137-175 J, respectively. As these approaches make it possible to calculate translational mechanical outputs specifically, they are useful and consistent concerning the analysis of translational motion of human body.     

Managing pain in labour. Part 2: non-pharmacological pain relief

The nearest and furthest points of clear vision were determined in 475 patients aged 6 to 16 years using an AKT-02 device after the optotype of Landolt's ring for 0.7 vision acuity. The mean values of accommodation volume for each age group were determined. They increase from 9.29 +/- 0.19 diopters at the age of 6 years to 12.25 +/- 0.23 diopters at 13, then gradually reduce to 10.0 +/- 0.19 diopters at 16. The descending slope of the curve coincides with the curve plotted by S.L. Shapovalov, who used the same method for measuring the accommodation volume. The volume of accommodation was 0.75 diopters reduced in myopic children in comparison with those with emmetropia.     

Acupuncture for pain relief during childbirth

Tobacco products regulated by the Bureau of Alcohol, Tobacco and Firearms (ATF), are classified at different excise tax rates according to the Code of Federal Regulations. These include the smoking (cigars, cigarettes, pipe tobacco and roll-your-own) and smokeless (chewing tobacco and snuff) tobacco products. The active principal components in all tobacco products belong to a class of compounds known as alkaloids. Nicotine is the major tobacco alkaloid, comprising about 98% of the total alkaloids. It is also the primary determinant of what constitutes a tobacco product from a regulatory standpoint. Nornicotine, anabasine and anatabine constitute the minor tobacco alkaloids of importance and interest to ATF. We have previously shown capillary electrophoresis (CE) to be a powerful analytical tool for monitoring nicotine in ATF-regulated products. Here we have extended those CE studies to (i) quantitate nicotine in ATF-regulated tobacco products and (ii) to characterize these different tobacco products according to their alkaloid profiles. Results from these studies will be presented.     

Epidural analgesia and uterine rupture during labour

Intravenous-bolus etoposide has modest activity in sarcomas when given daily for 3-5 days. Low frequent doses theoretically inhibit topoisomerase II activity over a longer duration and have been reported to have increased activity in small-cell lung cancer. A phase I trial of oral etoposide resulted in partial responses in two patients with soft-tissue sarcomas. To estimate more accurately the response rate for daily oral etoposide in sarcomas, we treated 25 patients with 50 mg/m2 per day by mouth for 21 days every 4 weeks. Treatment-related toxicity included > or = grade 2 neutropenia in 6 of the 25 patients and thrombocytopenia in 3. One brief partial response was observed (4%; 95% confidence interval for true response rate, 0-11%). Disease stabilized in five patients for periods ranging from 3 to 18 months. At this dose and on this schedule, daily oral etoposide appears to have little activity against soft-tissue sarcomas.     

Cesarean delivery: a randomized trial of epidural versus patient-controlled meperidine analgesia during labor

Barrett's esophagus is found in about 1% of the older population and in 3% to 5% of persons with gastroesophageal reflux. It is acquired more commonly by men and the prevalence increases with age. Most cases in the population remain undiagnosed. The incidence of adenocarcinoma of the esophagus and esophagogastric junction is increasing, both being related to Barrett's esophagus. Small areas of intestinal metaplasia are common but of uncertain significance.     

Comparison of 0.25% ropivacaine and bupivacaine for epidural analgesia for labor and vaginal delivery

STUDY OBJECTIVE: Part 1: To measure ropivacaine levels in the mother and infant at delivery after continuous lumbar epidural infusion. Part 2: To compare epidural ropivacaine to epidural bupivacaine for labor analgesia in regard to effectiveness, motor blockade, and maternal and neonatal effects. DESIGN: Part 1: Open-labelled, non-blind study. Part 2: Randomized, double-blind study. SETTING: Labor and delivery units of two academic hospitals. PATIENTS: Part 1: 20 ASA physical status I and II parturients in active labor. Part 2: 81 ASA physical status I and II parturients in active labor. INTERVENTIONS: For Part 1, 8 to 12 ml of 0.25% ropivacaine was administered through a lumbar epidural catheter to achieve a T10 dermatomal sensory level. An infusion of 0.25% ropivacaine, 8 to 10 ml/hr, maintained this sensory level. Maternal and umbilical cord blood samples obtained at delivery were analyzed for ropivacaine concentration. For Part 2, anesthetic management was similar to that previously described except patients were randomized to receive either 0.25% ropivacaine or 0.25% bupivacaine. Onset, regression, maximal spread of sensory block, and onset and degree of motor blockade were measured. Contraction pain as assessed using a visual analog scale (VAS), maternal blood pressure, and heart rate were determined every 5 minutes until a stable VAS-contraction score was achieved, and every 30 minutes thereafter. Neonatal assessment included Apgar scores and neurologic and adaptive capacity scores (NACS) at 15 minutes, 2 hours, and 24 hours. MEASUREMENTS AND MAIN RESULTS: For Part 1, the total and free maternal arterial concentrations of ropivacaine at delivery were 0.64 +/- 0.14 microgram/ml and 0.10 +/- .02 microgram/ml, respectively; the umbilical venous total and free concentrations were 0.19 +/- 0.03 microgram/ml and 0.12 +/- 0.07 microgram/ml, respectively (n = 12). The umbilical arterial and venous concentrations did not differ for both the free and total concentrations. For Part 2, there was no difference between ropivacaine and bupivacaine in the variables measured. Umbilical cord gases and Apgar scores were not different between the two groups; NACS were higher at 15 minutes and 2 hours in the ropivacaine group (p < 0.05) than the bupivacaine group. CONCLUSION: Both ropivacaine and bupivacaine produced excellent analgesia for labor with no major adverse effect on the mother or neonate.     

Comparison of patient-assisted epidural analgesia with continuous-infusion epidural analgesia for postoperative patients

Number of electroconvulsive therapy (ECT) treatments administered and severity of psychopathology confound the interpretation of clinical studies that address the relationship between the rate of administration of ECT and cognitive morbidity occasioned by the treatment. A preclinical study was therefore conducted to address the issue. Three groups (n = 8/group) of adult male Sprague-Dawley rats received six electroconvulsive shocks (ECS) in daily ECS, 3 ECS/week, and 2 ECS/week schedules; a fourth group (control; n = 8) received only sham ECS. From days 2 to 7 after the conclusion of the ECS/sham ECS course, the rats were monitored for learning on the Hebb-Williams complex maze. The control, 2 ECS/week, and 3 ECS/week groups showed significant learning by days 3, 5, and 7, respectively, while the daily ECS group showed no significant learning during the assessment period. This indicates that even when the cumulative effect of ECS on learning is controlled for, more frequent ECS is associated with slower learning. Extrapolating to clinical settings, it is suggested that wider spacing of ECT may lessen ECT-induced cognitive morbidity.     

The effects of Entonox and epidural analgesia on arterial oxygen saturation of women in labour

The arterial oxygen saturation of 40 mothers in the first stage of labour was monitored using pulse oximetry. Half the mothers received epidural analgesia and the rest inhaled Entonox for pain relief. Eight mothers in the Entonox group and six in the epidural group had at least one episode of significant hypoxia (saturation < 90%). There was little difference in the number of hypoxic episodes experienced by either group (29 in the Entonox and 21 in the epidural) although their mean duration and severity was greater in the Entonox group. Women in labour who inhale Entonox have an appreciable incidence of arterial desaturation. Epidural analgesia reduces the severity of hypoxic episodes although it does not eliminate them.     

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.     

The effect of segmental epidural analgesia on maternal and foetal acid-base balance, lactate, serum potassium and creatine phosphokinase during labour

Maternal and foetal acid-base balance, PaO2, lactate, potassium and creatine phosphokinase (CPK) were studied during the course of 28 induced labours. Every second mother received segmental epidural analgesia during the first stage of labour (epidural group), while the remaining mothers (who were given pethidine for pain relief, if necessary) acted as a control group. In the epidural group the patients had only minimal changes in acid-base balance and lactate concentration during the first stage. During the second stage lactate concentration increased. In the control group, on the other hand, the acid-base balance showed signs of hyperventilation and lactic acid accumulation during the first stage. The potassium changes were quite minimal and were not significantly different between the groups. The CPK level did not change during labour, but 2 and 4 h after delivery it was significantly elevated in both groups. The foetal acid-base balance, potassium, lactate and PaO2 values revealed no differences between the groups at any time. The CPK level in umbilical venous blood was significantly higher in the epidural group.     

Clinical evaluation of etidocaine in continuous caudal analgesia for pelvic floor repair and post-operative pain relief

A randomized double-blind trial compared 1-0% etidocaine and 1-5% lignocaine (both with 1/200,000 adrenaline), for caudal anaesthesia for pelvic floor repair. Etidocaine was highly effective for the surgical procedure, with rapid onset of action, adequate muscle relaxation and longer duration of action. Its use for post-operative analgesia may be hindered by the concomitant immobilization of the legs. The problem of tachyphylaxis with etidocaine needs further investigation.     

Intrathecal and epidural analgesia

Centroneuraxis analgesia has a place in the management of critically ill patients. With the safety of the intrathecally placed microcatheter now in question, epidural blockade is more suitable in the intensive care unit setting. The different mechanisms of action and the resultant synergy of local anesthetic agents and opioids, as well as their different side effects, are outlined. The contraindications to neuraxial blockade are discussed, and the role of epidural analgesia in the management of flail chest syndrome is addressed in detail.