Combined Sever''s release of the shoulder and osteotomy of the humerus for Erb''s palsy

We report a case of lumbar extradural abscess that presented 9 days after an elective Caesarean section performed under combined spinal-extradural anaesthesia. This was successfully treated conservatively with full recovery. The clinical course included development, and then resolution, of mild paraparesis. Conservative treatment of an extradural abscess in the obstetric population has not been described previously.     

Effects of ursodeoxycholic acid on conjugated bile acids and progesterone metabolites in serum and urine of patients with intrahepatic cholestasis of pregnancy

This study examined the effect of ambient temperature and feeding on brown adipose tissue (BAT) function and thermoregulation in lambs born either vaginally at term or by Caesarean section close to term. Immediately after birth lambs were placed in a warm (30 degrees C) or cool (15 degrees C) ambient temperature and measurements of colonic temperature and heat production recorded for 6 h. Lambs were fed 50 ml of colostrum when 5 h old. The amount of uncoupling protein and level of guanosine 5'diphosphate (GDP) binding in BAT was higher in vaginally delivered lambs than in lambs delivered by Caesarean section. For each delivery group, GDP binding was greater in lambs maintained at 30 degrees C than in lambs maintained at 15 degrees C. O2 consumption, CO2 production and colonic temperature only increased after feeding in lambs born by Caesarean section and maintained at 30 degrees C, a response that was accompanied by a decreased incidence of shivering. Irrespective of delivery temperature, plasma thyroid hormone concentrations and noradrenaline content of BAT were lower in lambs born by Caesarean section than in those born vaginally. Plasma cortisol concentrations were higher in lambs delivered by Caesarean section, as was adrenaline content of BAT in these lambs maintained at 30 degrees C. It is concluded that the thermoregulatory response to feeding in terms of changes in both recruitment of shivering and colonic temperature were observed only in lambs delivered by Caesarean section.     

Germline mutations in PTEN are an infrequent cause of genetic predisposition to breast cancer

Spinal extradural abscess is an infrequent, but serious complication to extradural catheters. Early diagnosis is essential for successful treatment. An extradural abscess may develop slowly over days to several weeks and symptoms may be vague and unspecific, delaying correct diagnosis. Meticulous supervision of the patients is required and must continue as long as an epidural catheter is in place and for some time after the catheter has been withdrawn. This case report describes a patient undergoing extensive reconstructive plastic surgery after a leg trauma. For postoperative pain treatment a continuous epidural infusion of bupivacaine was given. After 10-14 days an extradural abscess developed with increasing low back pain but without any neurologic symptoms. With antibiotics a complete resolution of the extradural abscess occurred, documented by computerized tomography (CT).     

Comparison between extradural infusion of ropivacaine or bupivacaine for the prevention of postoperative pain after total knee arthroplasty

We have compared the analgesia and motor block produced by extradural infusions of ropivacaine and bupivacaine after total knee arthroplasty. Fifty-two patients received 8 ml h1 of either 0.2% ropivacaine or 0.2% bupivacaine by extradural infusion for 24 h after operation. Analgesia was assessed by postoperative visual analogue scale (VAS) and morphine consumption. At rest these were low in both groups; median VAS was 0-13.3 mm for the ropivacaine group and 0-0.5 mm for the bupivacaine group. Over the 24 h of the infusion, the estimated (ropivacaine bupivacaine) difference in wound pain at rest was 5.6 mm (P = 0.017) and on passive movement 11.6 mm (P = 0.016). Median morphine consumption was 30.7 mg in the ropivacaine group and 20.5 mg in the bupivacaine group. In the ropivacaine group, 50% of patients compared with 19% in the bupivacaine group had no motor block 2 h after operation, increasing to 88% for ropivacaine and 56% for bupivacaine by 24 h. Bupivacaine produced significantly more frequent and intense motor block over the 24 h (P = 0.015).     

Epidural bupivacaine/fentanyl infusions vs. intermittent top-ups: a retrospective study of the effects on mode of delivery in primiparous women

This study was designed to determine whether the introduction of epidural infusions containing fentanyl and bupivacaine has affected the mode of delivery in primiparous women attending our maternity department. We reviewed retrospectively the computerized records of 4362 consecutive primiparous women in labour. All the women were admitted with the expectation of a vaginal delivery. The results were analysed using logistic regression analysis adjusted for age, weight, gestation, cervical dilatation at epidural insertion, use of oxytocin, the year of entry into the study and the type of epidural block received. In women receiving an epidural block at 3-6 cm cervical dilatation (n = 1534), those who received an infusion were significantly less likely to have an emergency Caesarean section than those having intermittent 'topups' (P = 0.0019). In the same subgroup of women, the Caesarean section rate specifically for failure to progress followed the same trend, but just failed to reach statistical significance (P = 0.058). This provides evidence to support the theory that epidural infusions containing a low dose bupivacaine/fentanyl combination may reduce the risk of Caesarean section in primiparous women.     

Extradural anaesthesia for caesarean section in a patient with syringomyelia and Chiari type I anomaly

We describe elective Caesarean section performed under extradural anaesthesia in a parturient with symptomatic syringomyelia and coexisting Chiari type I anomaly. Syringomyelia is reviewed and the anaesthetic implications of the condition discussed. Anaesthesia should be directed primarily at avoidance of increased intracranial pressure, which can cause sudden deterioration in these patients.     

Spread of spinal anaesthesia for caesarean section in singleton and twin pregnancies

We have compared the spread of spinal anaesthesia in parturients with singleton and those with twin pregnancies. Fifty-five unpremedicated patients with uncomplicated pregnancy scheduled for Caesarean section were allocated to two groups: group I = 35 singleton mothers; group II = 20 with twin pregnancy. Both groups received spinal anaesthesia with hyperbaric bupivacaine 10 mg (2 ml of 0.5%). Mean birthweight was 3290 (SD 452) g and 5008 (495) g in groups I and II (combined birthweights), respectively. We found a statistically significant difference in onset and maximal cephalad spread of spinal anaesthesia (group I median T5, range T8-T4; group II T3, range T6-T2). The mechanisms of higher cephalad spread of spinal anaesthesia in parturients may be a decrease in cerebrospinal fluid volume secondary to shunting of blood from the obstructed inferior vena cava to the extradural venous plexus and increased nerve sensitivity to local anaesthetics because of increased concentrations of progesterone. The twin pregnancy group had heavier, larger uteri and greater daily production of progesterone.     

Ropivacaine 7.5 mg/ml for elective caesarean section. A clinical and pharmacokinetic comparison of 150 mg and 187.5 mg

BACKGROUND: The new, long-acting local anaesthetic ropivacaine has shown less systemic toxicity than bupivacaine and a concentration of 7.5 mg/ml can therefore be used for epidural anaesthesia in Caesarean section. The present pilot study was undertaken to find indications for an optimal dosage by comparing the clinical effects, quality of anaesthesia and pharmacokinetics of ropivacaine 150 mg (lower dose = LD) vs 187.5 mg (higher dose = HD) for women undergoing elective Caesarean section under epidural anaesthesia. METHODS: Sixteen full-term women scheduled for elective Caesarean section in two equal-sized consecutive groups received 20 or 25 ml ropivacaine epidurally in this non-randomised, open study. Study parameters included sensory and motor blockade, circulatory response, intraoperative pain and discomfort, neonatal evaluation and pharmacokinetic determinations. RESULTS: Block height varied between T5 and T2 in the LD group, whereas the HD group produced 4 unnecessarily high blocks (C8 in 3 women and C7 in 1 woman). Surgical anaesthesia was excellent in both groups. Circulatory stability was pronounced in the LD group (no ephedrine given), while 4 women required ephedrine in the HD group. Neonatal outcome as judged by Apgar scores; umbilical blood gas determinations and NACS scores were excellent in both groups. The plasma concentration-time profiles indicated linearity in the concentration range studied, with similar clearance values to those reported previously. Placental drug equilibrium was rapid; however, the foetal drug exposure depended on intrauterine exposure time. CONCLUSIONS: 20-25 ml ropivacaine 7.5 mg/ml produced very satisfactory conditions for elective Caesarean section under epidural anaesthesia. In this small population, 150 mg ropivacaine seemed optimal, while 187.5 mg produced unnecessarily extended block height in 50% of the women.     

The influence of intrathecal fentanyl on the characteristics of subarachnoid block for caesarean section

Forty healthy parturients scheduled for elective Caesarean section were randomly allocated to receive either 0.3 ml 0.9% saline (control group, n = 20), or 15 micrograms (0.3 ml) fentanyl (treatment group, n = 20) added to 2.5 ml 0.5% hyperbaric bupivacaine given intrathecally in the sitting position. A sensory block to T4 was achieved after 6.5 min in those who received fentanyl compared to 8.0 min in the control group; this was not significantly different. The highest level of sensory block achieved in both groups was similar. Ephedrine was required earlier (p < 0.05) in those who received fentanyl but the total requirement of ephedrine intra-operatively was similar. Fentanyl significantly improved the quality of intra-operative surgical anaesthesia as none of the patients in the treatment group complained of discomfort compared with seven in the control group (p < 0.05). Similarly those in the treatment group had better comfort scores as evaluated by visual analogue score (p < 0.01). Regression of anaesthesia to T12 took longer (184 vs 156 min, p < 0.05) in those who received fentanyl but this did not affect the total requirement of morphine in the first 24 h after operation. There was no difference in the incidence of side effects in the mother and no adverse effects were detected in the baby. The results indicate that adding 15 micrograms fentanyl to hyperbaric bupivacaine for spinal anaesthesia markedly improves intra-operative anaesthesia for Caesarean section.     

Analgesia after upper abdominal surgery using extradural administration of a fixed dose of buprenorphine in combination with lignocaine given at two infusion rates: a comparative study

BACKGROUND: Extradural administration of combinations of local anaesthetics and opioids are frequently employed for postoperative pain relief. There is a scarcity of data on the analgesic effects of variations of the dose of local anaesthetic drug admixed to a fixed dose of opioid. METHODS: Twenty-four patients were investigated after elective upper abdominal surgery. During closure of the abdomen, 2% mepivacaine (8 ml) with buprenorphine 0.1 mg (0.5 ml) was given extradurally. After extubation, patients were randomly allocated to receive continuous extradural infusion of a fixed dose of buprenorphine (0.017 mg/h) in combination with 2% lignocaine at either 2.1 ml/h (low rate group, n = 14) or 6.3 ml/h (high rate group, n = 10). Postoperative pain at rest was assessed using visual analogue scale (VAS) scores and pain at movement by Prince Henry Pain Scale (PHPS) scores. Venous plasma lignocaine concentrations were measured. RESULTS: VAS scores at rest were similar in the two groups at 3 h postoperatively, whereas at 6-24 h postoperatively, VAS scores were higher in the low rate group than in the high rate group. PHPS scores were similar in the two groups at 3 h and at 18 h postoperatively, whereas at 6, 9, 12 and 24 h postoperatively, PHPS scores were higher in the low rate group than in the high rate group. Plasma lignocaine concentrations were higher at 23 h postoperatively in the high rate group than at 16 h in both groups, and at 23 h in the low rate group. At 3 h postoperatively, both the systolic and diastolic arterial pressures were higher in the low rate group than control values obtained on admission. Side effects were observed in one patient in the low rate group who complained of dizziness, and in one patient in the high rate group who complained of nausea. CONCLUSIONS: When added to a fixed dose of buprenorphine, continuous extradural infusion of 2% lignocaine at high rate provides better postoperative analgesia than when given at low rate without producing significant side effects.     

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.     

Vitamin C reduces ischemia-reperfusion injury in a rat epigastric island skin flap model

We have examined the effects of lumbar extradural administration of 1% etidocaine 10 ml on somatosensory evoked potentials to posterior tibial nerve stimulation measured in the cervical extradural space. Eight patients, anaesthetized with propofol and nitrous oxide, were studied before hysterectomy and a control group received a similar anaesthetic and 0.9% sodium chloride solution 10 ml in the lumbar extradural space. Etidocaine decreased significantly overall amplitude of the evoked potentials and the amplitudes of all peaks, between 30 and 50 min after extradural injection. The effects of etidocaine on spinal cord conduction were greater than those found previously for lignocaine and bupivacaine, suggesting that it is the local analgesic of choice for inhibiting afferent conduction.     

Effects of Ca2+ channel blockers on Ca2+ loading induced by metabolic inhibition and hyperkalemia in cardiomyocytes

The treatment of neuropathic pain with opioid analgesics is a matter of controversy among clinicians and clinician scientists. Although neuropathic pain is usually believed to be only slightly responsive to opioids, several studies show that satisfactory analgesia can be obtained if adequate doses are administered. In the present study, we tested the effectiveness of buprenorphine in 21 patients soon after thoracic surgery (nociceptive postoperative pain) and 1 month after surgery in the same 21 patients who developed postthoracotomy neuropathic pain with a burning, electrical and shooting quality. According to a double-blind randomized study, the analgesic dose (AD) of buprenorphine needed to reduce the long-term neuropathic pain by 50% (AD50) was calculated and compared to the AD50 in the immediate postoperative period. We found that long-term neuropathic pain could be adequately reduced by buprenorphine. However, the AD50 in neuropathic pain was significantly higher relative to the AD50 in the short-term postoperative pain, indicating a lower responsiveness of neuropathic pain to opioids. We also found a strict relationship between the short-term and long-term AD50, characterized by a saturating effect. In fact, if the AD50 soon after surgery was low, the AD50 increase in the long-term neuropathic pain was threefold. By contrast, if the AD50 soon after surgery was high, the AD50 in neuropathic pain was only slightly increased. This suggests that, though neuropathic pain is indeed less sensitive to opioids, in some neuropathic patients a large amount of opioid resistance is already present in other painful conditions.     

Diamorphine-bupivacaine mixture compared with plain bupivacaine for analgesia

We have studied the efficacy of two extradural infusions (10 ml h-1) in 50 patients in active labour. Patients in the diamorphine group (n = 25) received 0.0625% plain bupivacaine 6.25 mg h-1 mixed with 0.005% diamorphine 0.5 mg h-1 and those in the control group (n = 25) received 0.125% plain bupivacaine 12.5 mg h-1. Both groups received intermittent "top-ups" of 0.25% bupivacaine 10 ml when indicated. Although median pain scores during the infusion were similar in both groups, patients in the diamorphine group indicated greater satisfaction with the infusion (88% very satisfied, compared with 52% in the control group (P < 0.02)). There were no differences in the incidence of hypotension, instrumental vaginal delivery, number of "top-ups", duration of the second stage or extent of motor block. However, patients in the diamorphine group had a high incidence of pruritus (44%, compared with 0% in the control group (P < 0.01)).     

Patient-controlled epidural analgesia after caesarean section using a disposable device

We have evaluated the use of a disposable device, the Patient Controlled Epidural Infusor, for patient-controlled epidural analgesia (PCEA) using pethidine, for pain relief in the first 24 hours after elective Caesarean section. Patients using the Patient Controlled Epidural Infusor (n = 20) were compared with a control group (n = 20) who received PCEA using a standard electronic device. Efficacy, as assessed by visual analogue scores, was comparable to that achieved in the control group. Patient and nursing satisfaction was high and similar to that in the control group. There was a low incidence of side-effects with both devices. Patients using the disposable device used less pethidine than patients using the electronic device (median (interquartile range) 181 (100-275) mg versus 238 (213-375) mg; p = 0.035). Use of this disposable device is an acceptable alternative to more expensive and bulkier electronic devices for PCEA after Caesarean section.     

Cesarean section in a patient with cerebral ischemic pathology. Spinal anesthesia

The choice of anaesthesia for Caesarean sections, in patient with recent cerebral ischemic-hemorrhagic injuries, is a big problem. A case is reported of a woman submitted to Caesarean section in spinal anaesthesia who, in the first quarter, suffered an ischemic-hemorrhagic cerebral injury. Spinal anaesthesia was made by hyperbaric bupivacaine 0.5% at 10 mg dose + fentanyl 25 micrograms using 24G Sprotte needle. Spinal anaesthesia guarantees a good neuroendocrine protection to surgical aggression and a good hemodynamic stability. Hypotension prophylaxis by pre-filled is necessary and its treatment with ephedrine must be timely carried out. Risk of post-dural puncture headache, by atraumatic and very thin needles, is negligible. Spinal anaesthesia avoids general anaesthesia which may cause cardiovascular damages due to oro-tracheal intubation leading to possible cerebral damage. Induction-delivery time is more dangerous: the use of alogenate, oppioids, and/or some medicaments which may control the mother's adrenergic response, exhibit the newborn to risks.     

The effects of metyrapone (Metopiron) on the half-life time of phenazone (Antipyrine) in rabbits

The literature concerning perforation and imminent perforation of the caecum is reviewed. The greatest importance is attached to 5 cases of perforation of the caecum associated with paralytic ileus following Caesarean section. The caecal diameter was determined by radiography in 100 patients on the 3rd and 5th day after Caesarean section. At the same time the volume of subdiaphragmatic free gas was assessed. An average caecal diameter of 6.4 cm was found, which is not different from the findings in the normal population. Increasing caecal diameter during the puerperium gives rise to suspicion of the caecum. In 90% of the patients free subdiaphragmatic gas disappeared by the 5th day after Caesarean section.     

Effects of the gradually increasing dawn light stimulation on sleep feeling

In a double-blind, multicentre study 245 children aged 1-10 yr undergoing elective minor surgery as inpatients were randomly allocated to receive a single caudal extradural injection of 1 ml kg-1 of either 0.25% bupivacaine or 0.2% ropivacaine after induction of light general anaesthesia. The groups were comparable for age, weight, vital signs and duration of surgery. The onset time was similar for ropivacaine and bupivacaine (9.7 vs 10.4 min). Further analgesia was not required in 40% of children. The mean time to first analgesia in the remainder was 233 min in the bupivacaine group and 271 min in the ropivacaine group. No motor block was measurable in either group. Ropivacaine 2 mg kg-1 was as effective as bupivacaine 2.5 mg kg-1 for caudal analgesia in children.     

Sciatic nerve palsy following childbirth

Two cases are reported of sciatic nerve palsy after delivery by Caesarean section in primigravidae. One mother was slender and had an emergency Caesarean section for failure to progress with a breech presentation. Epidural analgesia during labour was extended for operative delivery. The other mother was obese, mildly hypertensive, had a large baby with a high head and was delivered by elective Caesarean section under epidural anaesthesia. She experienced severe intrapartum hypotension. Both patients suffered right sided sciatic nerve palsy. The aetiologies of obstetric palsies and those following regional block are reviewed and the importance of careful diagnosis and of avoiding peripheral nerve compression during regional block are emphasised.     

Relation of umbilical vein cortisol to neonatal bilirubin concentrations

Umbilical vein (UV) plasma cortisol levels were assayed at delivery after spontaneous labour, oxytocin-induced labour, prostaglandin E2-induced labour and after delivery by elective Caesarean section. Higher mean UV cortisol levels were observed after vaginal delivery than after delivery by elective Caesarean section. The highest mean UV cortisol level was observed in the PGE2 group which accords with the known ability of prostaglandins to increase steroid production. The significance of these findings is discussed.