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Tan HS, Tan CW, Sultana R, Chen HY, Chua T, Rahman N, Gandhi M, Sia ATH, Sng BL. The association between epidural labour analgesia and postpartum depression: a randomised controlled trial. Anaesthesia 2024; 79:357-367. [PMID: 37990597 DOI: 10.1111/anae.16178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 11/23/2023]
Abstract
There is conflicting evidence regarding the association between epidural labour analgesia and risk of postpartum depression. Most previous studies were observational trials with limited ability to account for confounders. We aimed to determine if epidural analgesia was associated with a significant change in the incidence of postpartum depression in this randomised controlled trial. We enrolled women aged 21-50 years old with a singleton fetus ≥ 36 weeks gestation. Patients were advised regarding available labour analgesic modalities during enrolment (epidural block; intramuscular pethidine; nitrous oxide; or intravenous remifentanil). On request for analgesia, patients were offered the modality that they had been allocated randomly to first. Blinded investigators recorded patient and obstetric characteristics within 24 h of delivery and assessed for postpartum depression at 6-10 weeks following delivery using the Edinburgh Postnatal Depression Scale (score ≥ 13 considered positive for postpartum depression). The modified intention-to-treat population consisted of all patients who received any form of labour analgesia, while per-protocol consisted of patients who received their randomised modality as their first form of labour analgesia. Of 881 parturients allocated randomly (epidural n = 441, non-epidural n = 440), we analysed 773 (epidural n = 389, non-epidural n = 384); 62 (15.9%) of women allocated to epidural group developed postpartum depression compared with 65 (16.9%) women allocate to the non-epidural group. There were no significant differences in the incidence of postpartum depression between the two groups (adjusted risk difference (95%CI) 1.6 (-3.0-6.3%), p = 0.49). Similar results were obtained with per-protocol analysis (adjusted risk difference (95%CI) -1.0 (-8.3-6.3%), p = 0.79). We found no significant difference in the risk of postpartum depression between patients who received epidural labour analgesia and those who utilised non-epidural analgesic modalities.
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Affiliation(s)
- H S Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore, Singapore
- Anaesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
| | - C W Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore, Singapore
- Anaesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
| | - R Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - H Y Chen
- Department of Psychological Medicine, KK Women's and Children's Hospital, Singapore, Singapore
- Paediatrics Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
| | - T Chua
- Department of Psychological Medicine, KK Women's and Children's Hospital, Singapore, Singapore
- Paediatrics Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
| | - N Rahman
- Department of Biostatistics, Singapore Clinical Research Institute, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - M Gandhi
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
- Department of Biostatistics, Singapore Clinical Research Institute, Singapore, Singapore
| | - A T H Sia
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore, Singapore
- Anaesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
| | - B L Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore, Singapore
- Anaesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
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Tan HS, Plichta JK, Kong A, Tan CW, Hwang S, Sultana R, Wright MC, Sia ATH, Sng BL, Habib AS. Risk factors for persistent pain after breast cancer surgery: a multicentre prospective cohort study. Anaesthesia 2023; 78:432-441. [PMID: 36639918 DOI: 10.1111/anae.15958] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 01/15/2023]
Abstract
Identifying factors associated with persistent pain after breast cancer surgery may facilitate risk stratification and individualised management. Single-population studies have limited generalisability as socio-economic and genetic factors contribute to persistent pain development. Therefore, this prospective multicentre cohort study aimed to develop a predictive model from a sample of Asian and American women. We enrolled women undergoing elective breast cancer surgery at KK Women's and Children's Hospital and Duke University Medical Center. Pre-operative patient and clinical characteristics and EQ-5D-3L health status were recorded. Pain catastrophising scale; central sensitisation inventory; coping strategies questionnaire-revised; brief symptom inventory-18; perceived stress scale; mechanical temporal summation; and pressure-pain threshold assessments were performed. Persistent pain was defined as pain score ≥ 3 or pain affecting activities of daily living 4 months after surgery. Univariate associations were generated using generalised estimating equations. Enrolment site was forced into the multivariable model, and risk factors with p < 0.2 in univariate analyses were considered for backwards selection. Of 210 patients, 135 (64.3%) developed persistent pain. The multivariable model attained AUC = 0.807, with five independent associations: age (OR 0.85 95%CI 0.74-0.98 per 5 years); diabetes (OR 4.68, 95%CI 1.03-21.22); pre-operative pain score at sites other than the breast (OR 1.48, 95%CI 1.11-1.96); previous mastitis (OR 4.90, 95%CI 1.31-18.34); and perceived stress scale (OR 1.35, 95%CI 1.01-1.80 per 5 points), after adjusting for: enrolment site; pre-operative pain score at the breast; pre-operative overall pain score at rest; postoperative non-steroidal anti-inflammatory drug use; and pain catastrophising scale. Future research should validate this model and evaluate pre-emptive interventions to reduce persistent pain risk.
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Affiliation(s)
- H S Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - J K Plichta
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - A Kong
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - C W Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - S Hwang
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - R Sultana
- Centre for Quantitative Medicine, Singapore
| | - M C Wright
- Division of Women's Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - A T H Sia
- KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - B L Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - A S Habib
- Division of Women's Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Tan HS, Liu N, Sultana R, Han NLR, Tan CW, Zhang J, Sia ATH, Sng BL. Prediction of breakthrough pain during labour neuraxial analgesia: comparison of machine learning and multivariable regression approaches. Int J Obstet Anesth 2020; 45:99-110. [PMID: 33121883 DOI: 10.1016/j.ijoa.2020.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 07/27/2020] [Accepted: 08/17/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Risk-prediction models for breakthrough pain facilitate interventions to forestall inadequate labour analgesia, but limited work has used machine learning to identify predictive factors. We compared the performance of machine learning and regression techniques in identifying parturients at increased risk of breakthrough pain during labour epidural analgesia. METHODS A single-centre retrospective study involved parturients receiving patient-controlled epidural analgesia. The primary outcome was breakthrough pain. We randomly selected 80% of the cohort (training cohort) to develop three prediction models using random forest, XGBoost, and logistic regression, followed by validation against the remaining 20% of the cohort (validation cohort). Area-under-the-receiver operating characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were used to assess model performance. RESULTS Data from 20 716 parturients were analysed. The incidence of breakthrough pain was 14.2%. Of 31 candidate variables, random forest, XGBoost and logistic regression models included 30, 23, and 15 variables, respectively. Unintended venous puncture, post-neuraxial analgesia highest pain score, number of dinoprostone suppositories, neuraxial technique, number of neuraxial attempts, depth to epidural space, body mass index, pre-neuraxial analgesia oxytocin infusion rate, maternal age, pre-neuraxial analgesia cervical dilation, anaesthesiologist rank, and multiparity, were identified in all three models. All three models performed similarly, with AUC 0.763-0.772, sensitivity 67.0-69.4%, specificity 70.9-76.2%, PPV 28.3-31.8%, and NPV 93.3-93.5%. CONCLUSIONS Machine learning did not improve the prediction of breakthrough pain compared with multivariable regression. Larger population-wide studies are needed to improve predictive ability.
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Affiliation(s)
- H S Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - N Liu
- Duke-NUS Medical School, Singapore; Health Services Research Centre, Singapore Health Services, Singapore
| | | | - N-L R Han
- Division of Clinical Support Services, KK Women's and Children's Hospital, Singapore
| | - C W Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - J Zhang
- Duke-NUS Medical School, Singapore
| | - A T H Sia
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - B L Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore; Duke-NUS Medical School, Singapore.
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Sng BL, Sia ATH, Lim Y, Woo D, Ocampo C. Comparison of Computer-integrated Patient-controlled Epidural Analgesia and Patient-controlled Epidural Analgesia with a Basal Infusion for Labour and Delivery. Anaesth Intensive Care 2019; 37:46-53. [DOI: 10.1177/0310057x0903700119] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- B. L. Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - A. T. H. Sia
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - Y. Lim
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - D. Woo
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - C. Ocampo
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
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Kinsella SM, Carvalho B, Dyer RA, Fernando R, McDonnell N, Mercier FJ, Palanisamy A, Sia ATH, Van de Velde M, Vercueil A. International consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia. Anaesthesia 2017; 73:71-92. [DOI: 10.1111/anae.14080] [Citation(s) in RCA: 233] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2017] [Indexed: 11/28/2022]
Affiliation(s)
- S. M. Kinsella
- Department of Anaesthesia; St Michael's Hospital; Bristol UK
| | - B. Carvalho
- Department of Anesthesiology; Stanford University School of Medicine; Stanford CA USA
| | - R. A. Dyer
- Department of Anaesthesia and Perioperative Medicine; University of Cape Town; South Africa
| | - R. Fernando
- Department of Anaesthesia; Hamad Women's Hospital; Doha Qatar
| | - N. McDonnell
- Department of Anaesthesia and Pain Medicine; King Edward Memorial Hospital for Women; Subiaco Australia
| | - F. J. Mercier
- Département d'Anesthésie-Réanimation; Hôpital Antoine Béclère; Clamart France
| | - A. Palanisamy
- Department of Anesthesiology; Washington University School of Medicine; St. Louis MO USA
| | - A. T. H. Sia
- Department of Women's Anaesthesia; KK Women's and Children's Hospital; Singapore
| | - M. Van de Velde
- Department of Anesthesiology; UZ Leuven; Leuven Belgium
- Department of Cardiovascular Sciences; KU Leuven; Leuven Belgium
| | - A. Vercueil
- Department of Anaesthesia and Intensive Care Medicine; King's College Hospital NHS Foundation Trust; London UK
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Leong WL, Sng BL, Zhang Q, Han NLR, Sultana R, Sia ATH. A case series of vital signs-controlled, patient-assisted intravenous analgesia (VPIA) using remifentanil for labour and delivery. Anaesthesia 2017; 72:845-852. [PMID: 28418067 DOI: 10.1111/anae.13878] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2017] [Indexed: 11/27/2022]
Abstract
Intravenous remifentanil patient-controlled analgesia can be used during labour as an alternative to epidural analgesia. Adverse effects of opioids, including hypoxia and bradycardia, may lead to maternal morbidity and mortality. We devised an interactive feedback system based on a clinical proportional algorithm, to continuously monitor for adverse effects to enhance safety and better titrate analgesia. This vital signs-controlled, patient-assisted intravenous analgesia with remifentanil used a prototype delivery system linked to a pulse oximeter that evaluated maternal oxygen saturation and heart rate continuously. With this system, we detected oxygen saturation < 95% for more than 60 s in 15 of 29 subjects (52%); and heart rate < 60 min-1 for more than 60 s in 7 of 29 subjects (24%) during use. The system automatically responded appropriately by reducing the dosages and temporarily halting remifentanil administration, thus averting further hypoxia and bradycardia.
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Affiliation(s)
- W L Leong
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - B L Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Q Zhang
- SingHealth Anaesthesiology Residency Program, Singapore
| | - N L R Han
- Division of Clinical Support Services, KK Women's and Children's Hospital, Singapore
| | - R Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - A T H Sia
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore
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Yeo J, Sultana R, Assam PN, Sng BL, Sia ATH. Abstract PR222. Anesth Analg 2016. [DOI: 10.1213/01.ane.0000492620.53142.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Du W, Chen HY, Sultana R, Assam PN, Sia ATH, Sng BL. Abstract PR196. Anesth Analg 2016. [DOI: 10.1213/01.ane.0000492595.98883.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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10
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Sng BL, Tan HS, Sia ATH. Closed-loop double-vasopressor automated system vs manual bolus vasopressor to treat hypotension during spinal anaesthesia for caesarean section: a randomised controlled trial. Anaesthesia 2013; 69:37-45. [DOI: 10.1111/anae.12460] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2013] [Indexed: 11/29/2022]
Affiliation(s)
- B. L. Sng
- Department of Women's Anaesthesia; KK Women's and Children's Hospital; Singapore
| | - H. S. Tan
- Duke-NUS Graduate Medical School; Singapore
| | - A. T. H. Sia
- Department of Women's Anaesthesia; KK Women's and Children's Hospital; Singapore
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Kulkarni SS, Teoh WHL, Sia ATH, Nair S. Ruptured uterine artery pseudoaneurysm: an overlooked cause of late postpartum haemorrhage. Acta Anaesthesiol Belg 2013; 64:159-162. [PMID: 24605417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
We report an exceptional case of secondary postpartum hemorrhage (PPH) twenty days after cesarean delivery, resulting from a ruptured uterine artery pseudoaneurysm (UAP). The diagnosis was initially confounded by a septic shock necessitating inotropic support in the intensive care unit. Intense vaginal bleeding occurred eleven days after uterine curettage. Doppler ultrasound showed an anechoic focus in the inferior part of the uterus with turbulent flow. Bilateral internal iliac artery angiograms revealed a left uterine artery pseudoaneurysm that was successfully embolized. UAP is a rare cause of unexplained PPH that requires a high index of suspicion for diagnosis. This first report in the anesthesia literature serves to focus our awareness on its possible occurrence, and gives track to its management. Pitfalls in UAP diagnostic are highlighted (delayed presentation, possibility of spontaneous hemostasis, and lack of typical findings on colour Doppler sonography in hypotensive patients). These pitfalls may further be confounded by a concomitant sepsis. Angiography and selective uterine artery embolization is the treatment of choice.
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MESH Headings
- Aneurysm, False/complications
- Aneurysm, False/diagnostic imaging
- Aneurysm, False/therapy
- Aneurysm, Ruptured/complications
- Aneurysm, Ruptured/diagnostic imaging
- Aneurysm, Ruptured/therapy
- Anti-Bacterial Agents/therapeutic use
- Anti-Infective Agents/therapeutic use
- Ceftriaxone/therapeutic use
- Cesarean Section
- Female
- Follow-Up Studies
- Humans
- Metronidazole/therapeutic use
- Postpartum Hemorrhage/etiology
- Postpartum Hemorrhage/therapy
- Pregnancy
- Radiography
- Shock, Septic/complications
- Shock, Septic/diagnosis
- Shock, Septic/drug therapy
- Treatment Outcome
- Ultrasonography, Doppler/methods
- Uterine Artery/diagnostic imaging
- Uterine Artery Embolization/methods
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Affiliation(s)
- S S Kulkarni
- Department of Women's Anaesthesia, KK Women's & Children's Hospital, Singapore
| | - W H L Teoh
- Department of Women's Anaesthesia, KK Women's & Children's Hospital, Singapore
| | - A T H Sia
- Department of Women's Anaesthesia, KK Women's & Children's Hospital, Singapore
| | - S Nair
- Department of Obstetrics and Gynaecology, KK Women's & Children's Hospital, Singapore
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Sia ATH, Tan HS, Sng BL. Closed-loop double-vasopressor automated system to treat hypotension during spinal anaesthesia for caesarean section: a preliminary study. Anaesthesia 2012; 67:1348-55. [DOI: 10.1111/anae.12000] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Halaseh BK, Sukkar ZF, Hassan LH, Sia ATH, Bushnaq WA, Adarbeh H. The use of ProSeal laryngeal mask airway in caesarean section--experience in 3000 cases. Anaesth Intensive Care 2011; 38:1023-8. [PMID: 21226432 DOI: 10.1177/0310057x1003800610] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Rapid sequence induction is currently the recommended technique in general anaesthesia for caesarean section. However, the usefulness of the ProSeal laryngeal mask airway as a rescue airway in the event of difficult or failed intubation has been recognised in numerous case reports. In this study, we report the experience of the use of the ProSeal laryngeal mask in 3000 elective caesarean sections in a single centre, using a method of insertion that allows a rapid establishment of a patent airway together with gastric drainage.
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Affiliation(s)
- B K Halaseh
- Department of Anesthesia, Farah Hospital, Amman, Jordan
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Teoh WHL, Lee KM, Suhitharan T, Yahaya Z, Teo MM, Sia ATH. Comparison of the LMA Supreme vs the i-gel in paralysed patients undergoing gynaecological laparoscopic surgery with controlled ventilation. Anaesthesia 2010; 65:1173-9. [PMID: 20958278 DOI: 10.1111/j.1365-2044.2010.06534.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We compared the efficacy of the inflatable cuff of the LMA Supreme against the non-inflatable i-gel cuff in providing an adequate seal for laparoscopic surgery in the Trendelenburg position in 100 female patients. There was no difference in our primary outcome, oropharyngeal leak pressure, between the LMA Supreme and the i-gel (mean (SD) 26.4 (5.1) vs 25.0 (5.7) cmH(2) O, respectively; p = 0.18). Forty-seven (94%) LMA Supremes and 48 (96%) i-gels were successfully inserted on the first attempt, with similar ease, and comparable times to the first capnograph trace (mean (SD) 14.3 (4.7) s for the LMA Supreme vs 15.4 (8.2) s for the i-gel; p = 0.4). Gastric tube insertion was easier and achieved more quickly with the LMA Supreme vs the i-gel (9.0 (2.5) s vs 15.1 (7.3) s, respectively; p < 0.001). After creation of the pneumoperitoneum, there was a smaller difference between expired and inspired tidal volumes with the LMA Supreme (21.5 (15.2) ml) than with the i-gel (31.2 (23.5) ml; p = 0.009). There was blood on removal of two LMA Supremes and one i-gel. Four patients in the LMA Supreme group and one patient in the i-gel group experienced mild postoperative sore throat.
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Affiliation(s)
- W H L Teoh
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore.
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16
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Teoh WHL, Saxena S, Shah MK, Sia ATH. Comparison of three videolaryngoscopes: Pentax Airway Scope, C-MAC™, Glidescope® vs the Macintosh laryngoscope for tracheal intubation*. Anaesthesia 2010; 65:1126-32. [DOI: 10.1111/j.1365-2044.2010.06513.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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17
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Desai S, Lim Y, Tan CH, Sia ATH. A randomised controlled trial of hyperbaric bupivacaine with opioids, injected as either a mixture or sequentially, for spinal anaesthesia for caesarean section. Anaesth Intensive Care 2010; 38:280-4. [PMID: 20369760 DOI: 10.1177/0310057x1003800209] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
It is common practice to mix opioids with hyperbaric bupivacaine in a single syringe before intrathecal injection of the mixture. Mixing these drugs may alter the density of the hyperbaric solution, affecting the spread of local anaesthetic and opioid. Forty-eight women having elective caesarean section under spinal anaesthesia were recruited to this double-blind, randomised trial. Group M (n=24) received 2 ml of 0.5% hyperbaric bupivacaine plus morphine 100 microg plus fentanyl 15 microg, mixed in a syringe prior to administration. Group S (n=24) received 2 ml of 0.5% bupivacaine through one syringe, followed by morphine 100 microg plus fentanyl 15 microg through a separate syringe. All patients received patient-controlled intravenous morphine for 24 hours postoperatively. Block characteristics, postoperative pain scores and morphine use were noted. The patients in Group M had higher levels of sensory block to cold than those in Group S (median T2 vs. T3) (P = 0.003). Five patients in Group M and none in Group S had a block to cold > or = T1 (P = 0.02). There was no difference between groups in the incidence of hypotension, need for vasopressor or side-effects. Morphine consumption was significantly higher in group M (13.3 +/- 11.2 vs. 6.2 +/- 7.2 mg, P = 0.015). Mixing of fentanyl and morphine with hyperbaric bupivacaine results in a higher level of sensory block than sequential administration of bupivacaine then opioid and may be associated with higher postoperative opioid requirement.
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Affiliation(s)
- S Desai
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
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18
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Sng BL, Sia ATH, Quek K, Woo D, Lim Y. Incidence and risk factors for chronic pain after caesarean section under spinal anaesthesia. Anaesth Intensive Care 2010; 37:748-52. [PMID: 19775038 DOI: 10.1177/0310057x0903700513] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study investigated the incidence and risk factors associated with chronic pain after elective caesarean section under spinal anaesthesia in an Asian population. A prospective cohort study was conducted among subjects who underwent elective caesarean section under spinal anaesthesia, with morphine patient-controlled analgesia administered for 24 hours postoperatively. Perioperative, surgical and obstetric factors were investigated prospectively. Phone surveys were conducted to identify risk factors associated with chronic pain. A total of 857 subjects completed both the perioperative study and phone survey. The incidence of wound scar pain for three months after surgery was 9.2% (79). Of the 51 subjects with persistent pain at the time of subsequent survey, 9.8% (n = 5) had constant pain, 9.8% (n = 5) had daily pain and 23.5% (n = 12) had pain intermittently, at an interval of days. The independent risk factors for development of chronic pain were higher pain scores recalled in the immediate postoperative period (odds ratio [OR, 95% confidence interval] 1.348 [1.219 to 1.490], P = 0.0001), pain present elsewhere (OR 2.471 [1.485 to 4.112], P = 0.001) and non-private insurance status (OR 1.679 [1.034 to 2.727], P = 0.036). The two most common sites of pain other than wound pain were back pain (n = 316) and migraine (n = 87).
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Affiliation(s)
- B L Sng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
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Teoh WHL, Sia ATH, Fun WLL. A prospective, randomised, cross-over trial comparing the EndoFlex®and standard tracheal tubes in patients with predicted easy intubation. Anaesthesia 2009; 64:1172-7. [DOI: 10.1111/j.1365-2044.2009.06058.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Teoh WHL, Shah MK, Sia ATH. Randomised comparison of Pentax AirwayScope and Glidescope for tracheal intubation in patients with normal airway anatomy. Anaesthesia 2009; 64:1125-9. [DOI: 10.1111/j.1365-2044.2009.06032.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lee AKY, Tey JBL, Lim Y, Sia ATH. Comparison of the Single-use LMA Supreme with the Reusable ProSeal LMA for Anaesthesia in Gynaecological Laparoscopic Surgery. Anaesth Intensive Care 2009; 37:815-9. [DOI: 10.1177/0310057x0903700537] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Laryngeal Mask Airway Supreme (LMAS) is a new, single-use laryngeal mask airway with gastric access. We conducted a randomised controlled study comparing the LMAS with the reusable ProSeal Laryngeal Mask Airway (PLMA) in 70 patients undergoing general anaesthesia with paralysis for gynaecological laparoscopic surgery. Our primary outcome measure was the oropharynegal leak pressure. We also compared the two devices for ease of insertion, adequacy of ventilation and incidence of complications. Both devices had similar rates of successful insertion at the first attempt (LMAS 94% vs PLMA 91%). There was no difference in the time to establish an effective airway (LMAS 25±22 vs PLMA 24±9 seconds), although gastric tube insertion was faster for the LMAS (5±1 vs 7±3 seconds, P <0.001). The mean oropharyngeal leak pressure in the LMAS was significantly lower than in the PLMA (27.9±4.7 vs 31.7±6.3 cmH2O, P=0.007). This was consistent with a lower maximum tidal volume achieved with the LMAS (481±76 vs 515±63 ml, P=0.044). We found that after 60 minutes the cuff pressure was significantly higher in the PLMA (110±21 vs 57±8 cmH2O, P <0.001). There was no difference in the ability to provide adequate ventilation and oxygenation during anaesthesia. Complication rates were similar. We conclude that the oropharyngeal leak pressure and the maximum achievable tidal volume are lower with the LMAS than with the PLMA.
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Affiliation(s)
- A. K. Y. Lee
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
- Department of Anaesthesia and Surgical Intensive Care, Singapore General Hospital
| | - J. B. L. Tey
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - Y. Lim
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - A. T. H. Sia
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
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Leo S, Lim Y, Sia ATH. Analgesic efficacy using loss of resistance to air vs. saline in combined spinal epidural technique for labour analgesia. Anaesth Intensive Care 2009; 36:701-6. [PMID: 18853590 DOI: 10.1177/0310057x0803600512] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Identification of the epidural space is often performed using the loss of resistance technique to either air or saline. We sought to investigate if the medium used affected the quality of analgesia obtained by parturients who received labour epidurals. We conducted a retrospective audit of labour epidurals performed on nulliparous parturients in our institution from May 2003 to March 2005. All epidural catheters were inserted by senior obstetric anaesthetists using a combined spinal epidural technique. The following information was recorded: parturients' demographic data, loss of resistance technique used, type and amount of local anaesthetic solution administered, complications encountered during procedure, pre-block and post-block pain scores, incidence of breakthrough pain requiring supplemental medication and post-block side-effects. Data from 2848 patients were collected and analysed; 56% of patients made up the saline group and 44% the air group. Patients in both groups had similar demographic profiles and similar incidences of complications and post-block side-effects. However patients in the air group had a higher incidence of recurrent breakthrough pain P = 0.023). We also identified three other factors that were associated with an increased incidence of recurrent breakthrough pain; administration of pre-block oxytocin, sitting position of the parturient during the procedure and the use of intrathecal bupivacaine for induction of analgesia. Our findings suggest that a loss of resistance to air is associated with a higher incidence of recurrent breakthrough pain among parturients who received combined spinal epidural analgesia for labour than a loss of resistance to saline.
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Affiliation(s)
- S Leo
- Department of Women's Anaesthesia, Kandang Kerbau Women's and Children's Hospital, Singapore
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Sng BL, Pay LL, Sia ATH. Comparison of 2% Lignocaine with Adrenaline and Fentanyl, 0.75% Ropivacaine and 0.5% Levobupivacaine for Extension of Epidural Analgesia for Urgent Caesarean Section after Low Dose Epidural Infusion during Labour. Anaesth Intensive Care 2008; 36:659-64. [DOI: 10.1177/0310057x0803600505] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Low dose local anaesthetic and fentanyl epidural solutions are commonly ‘topped-up’ for urgent caesarean section. However, the block characteristics associated with newer local anaesthetics such as ropivacaine 0.75% and levobupivacaine 0.5% have not been fully determined. In a randomised double-blinded controlled clinical trial, we compared 2% lignocaine with adrenaline and fentanyl (LAF), 0.75% ropivacaine and 0.5% levobupivacaine for extension of low dose epidural analgesia for urgent caesarean section in 90 Asian parturients. There was no significant difference in the median, interquartile range, time to T4 loss of sensation to cold between LAF (9.5, 7.0 to 13.3 minutes), 0.75% ropivacaine (10.0, 7.0 to 15.0 minutes) and 0.5% levobupivacaine (10.0, 7.0 to 15.0 minutes). No woman required conversion to general anaesthesia. The supplementation rate did not differ between groups. Levobupivacaine provided a longer duration of sensory block compared to LAF, but a similar duration to 0.75% ropivacaine. Under the conditions of this study there was no significant difference in time to surgical readiness (defined as loss of sensation to cold to T4) between LAF, 0.75% ropivacaine and 0.5% levobupivacaine groups. Ropivacaine and levobupivacaine are suitable alternatives for extending epidural analgesia for urgent caesarean section.
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Affiliation(s)
- B. L. Sng
- Department of Women's Anaesthesia, KK Women s and Children s Hospital, Singapore
| | - L. L. Pay
- Department of Women's Anaesthesia, KK Women s and Children s Hospital, Singapore
| | - A. T. H. Sia
- Department of Women's Anaesthesia, KK Women s and Children s Hospital, Singapore
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Abstract
We report a case of a parturient who was well antenatally but presented with oliguria following delivery. The possibility of postpartum preeclampsia was obscured by simultaneous postpartum haemorrhage. Ergometrine was given and she suffered an eclamptic seizure shortly after. We discuss the diagnostic difficulties presented by simultaneous presentation of postpartum preeclampsia and haemorrhage and the likelihood that ergometrine precipitated eclampsia in a patient at risk. While ergometrine is an effective drug for the management of uterine atony, its potential role in precipitating eclampsia must be considered.
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Affiliation(s)
- S. Y. Ng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - F. Ithnin
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - A. T. H. Sia
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - C. C. M. Ng
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
- Department of General Obstetrics and Gynaecology
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Lim Y, Sia ATH. Dispelling the myths of epidural pain relief in childbirth. Singapore Med J 2006; 47:1096-100. [PMID: 17139411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Affiliation(s)
- Y Lim
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore.
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Lim Y, Sia ATH, Ocampo C. Automated regular boluses for epidural analgesia: a comparison with continuous infusion. Int J Obstet Anesth 2005; 14:305-9. [PMID: 16154735 DOI: 10.1016/j.ijoa.2005.05.004] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2004] [Accepted: 05/01/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intermittent epidural bolus dosing is a method of drug delivery that can prolong the duration of labour analgesia induced by a combined spinal epidural (CSE). In this randomized, double-blinded study, we compared the analgesic efficacy of two drug delivery systems: regular intermittent epidural boluses and continuous epidural infusion and assessed the incidence of breakthrough pain after CSE. METHODS With the approval of the Hospital Ethics Committee, we recruited 60 parturients into this randomized controlled trial. A CSE was performed with intrathecal fentanyl 25 mug in all patients. The parturients were then randomly allocated into two groups. The infusion group received a continuous epidural infusion of levobupivacaine 0.1% with fentanyl 2 microg/mL at a rate of 10 mL/h. The bolus group received 5-mL epidural boluses every half hour. The sample size was computed to detect a 40% reduction in the rate of breakthrough pain. RESULTS The bolus group had a lower incidence of breakthrough pain than the infusion group (10% vs. 37%, P < 0.05). The bolus group also had significantly higher satisfaction scores for labour analgesia: 97+/-8 (mean+/-SD) vs. 89+/-7 (P < 0.05). CONCLUSION Automated regular bolus delivery of epidural analgesia when compared with continuous infusion decreased the incidence of breakthrough pain and increased maternal satisfaction. In a busy obstetric unit, this may also serve to decrease the anesthetists' workload.
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Affiliation(s)
- Y Lim
- Department of Anesthesia, Obstetrics and Gynecology, KK Women's and Children's Hospital, Singapore.
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Liu EHC, Sia ATH. Rates of caesarean section and instrumental vaginal delivery in nulliparous women after low concentration epidural infusions or opioid analgesia: systematic review. BMJ 2004; 328:1410. [PMID: 15169744 PMCID: PMC421779 DOI: 10.1136/bmj.38097.590810.7c] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the effects of low concentration epidural infusions of bupivacaine with parenteral opioid analgesia on rates of caesarean section and instrumental vaginal delivery in nulliparous women. DATA SOURCES Medline, Embase, the Cochrane controlled trials register, and handsearching of the International Journal of Obstetric Anesthesia. STUDY SELECTION Randomised controlled trials comparing low concentration epidural infusions with parenteral opioids. DATA SYNTHESIS Seven trials fulfilled the inclusion criteria for meta-analysis. Epidural analgesia does not seem to be associated with an increased risk of caesarean section (odds ratio 1.03, 95% confidence interval 0.71 to 1.48) but may be associated with an increased risk of instrumental vaginal delivery (2.11, 0.95 to 4.65). Epidural analgesia was associated with a longer second stage of labour (weighted mean difference 15.2 minutes, 2.1 to 28.2 minutes). More women randomised to receive epidural analgesia had adequate pain relief, with fewer changing to parenteral opioids than vice versa (odds ratio 0.1, 0.05 to 0.22). CONCLUSIONS Epidural analgesia using low concentration infusions of bupivacaine is unlikely to increase the risk of caesarean section but may increase the risk of instrumental vaginal delivery. Although women receiving epidural analgesia had a longer second stage of labour, they had better pain relief.
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Affiliation(s)
- E H C Liu
- Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074.
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Loke GPY, Chan EHY, Sia ATH. The effect of 10 degrees head-up tilt in the right lateral position on the systemic blood pressure after subarachnoid block for Caesarean section. Anaesthesia 2002; 57:169-72. [PMID: 11871954 DOI: 10.1046/j.1365-2044.2002.02227.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Forty women presenting for elective Caesarean section under spinal anaesthesia were randomly assigned to have anaesthesia induced in the right lateral position either in the horizontal position or with 10 degrees head-up tilt. Hyperbaric bupivacaine 2 ml 0.5% with 0.1 mg of morphine was injected intrathecally before the parturients were placed in the supine position with 15 degrees left lateral tilt. Blood pressure and heart rate were monitored every minute and the sensory level (loss of sharp sensation to pinprick) was monitored every 3 min until clamping of the umbilical cord. Ephedrine 6 mg was given every minute that the systolic blood pressure decreased below 90 mmHg. The mean systolic blood pressure during the first 5 min after induction of spinal anaesthesia was lower in the control group compared to the tilted group (99 mmHg vs. 109 mmHg; p = 0.043). The upper limit of block was higher in the control group compared to the tilted group (p = 0.002). The use of 10 degrees head-up tilt resulted in a reduced incidence of hypotension initially and less extensive sensory block.
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Affiliation(s)
- G P Y Loke
- Department of Anaesthesia (Obstetrics & Gynaecology), KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899
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