The Effects of an External Nasal Dilator on Labor

Background

The aim of this study was to assess the effect of an external nasal dilator on several variables characterizing labor in both mother and fetus.

Methods

One hundred and fifty primigravida women in active labor were randomized to wear, throughout labor, either a dilator spring-loaded nasal strip or a placebo device. Data were obtained during labor and compared between the groups. After delivery, the satisfaction rate was assessed.

Results

No differences were found between the study and the control group regarding rate of induction or augmentation of labor as well as Montevideo units reached, frequency of rupture of membranes, duration of the active phase and second stage of labor, usage of epidural analgesia, normal fetal heart pattern, meconium-stained amniotic fluid, and neonatal well being. Length of maternal and neonatal hospitalization also did not differ between the groups. Satisfaction rate was significantly higher in parturient women wearing nasal strips with a dilator spring than in parturient women wearing a placebo spring (P < 0.0001).

Conclusion

Nasal strips do not change the course but ameliorate the quality of labor by improving the ease of breathing. Nasal dilators sustain the respiratory effort associated with the long process of labor and may control the switch from nasal to oronasal breathing during delivery.

Respiratory events with sugammadex vs. neostigmine following laparoscopic sleeve gastrectomy: a prospective pilot study assessing neuromuscular reversal strategies

Abdominal surgery in obese patients may be associated with pulmonary morbidity, and mortality. Some patients may arrive in the PACU with residual paralysis. The purpose of this study was to find out if there was an association between the type of muscle relaxant reversal agent and the development of postoperative respiratory events in patients undergoing laparoscopic sleeve gastrectomy surgery.

METHODS

From September 2012 to February 2013, in a prospective randomized pilot study, two different muscle relaxant reversal agents were administered at the end of surgery in 57 patients undergoing laparoscopic sleeve gastrectomy: sugammadex 2 mg/kg (32 patients) vs. neostigmine 2.5 mg (25 patients). We compared the occurrence of early and late respiratory events/complications by the type of reversal agent. Postoperative respiratory rate, oxyhemoglobin saturation (SpO₂), number of patients with SpO₂ lower than 95% in PACU, the minimum value of SpO₂ in PACU, train-of four counts (TOF) before reversal, unexpected ICU admissions, duration of hospitalization and incidence of reintubation were recorded.

RESULTS

SpO₂ in the PACU was significantly lower in the neostigmine group - 95.80 (± 0.014)) vs. in sugammadex group - 96.72 (± 0.011) (p < 0.01), despite a lower TOF count measured in the sugammadex group before reversal, meaning a deeper level of residual relaxation in this group before the administration of the reversal agent (2.53 ± 0.98 vs. 3.48 ± 0.58 p < 0.01). Also, the minimal SpO₂ was significantly lower in the PACU in the neostigmine group: 93% vs. 94% (p = 0.01). Respiratory rates were not different. After the administration of reversal, both groups had TOF counts of 4 with no fade assessed visually. There were no postoperative respiratory events or complications.

CONCLUSIONS

The use of sugammadex (as compared to neostigmine) as a reversal agent following laparoscopic sleeve gastrectomy surgery was associated with higher postoperative SpO₂ despite the lower TOF count before the administration of reversal agent. Despite the statistical difference in SpO₂, its clinical importance seems to be minimal. The lack of difference in the other measured variables may stem from the small number of patients studied (pilot).

Residual Curarization and Postoperative Respiratory Complications Following Laparoscopic Sleeve Gastrectomy. The Effect of Reversal Agents: Sugammadex vs. Neostigmine

BACKGROUND

Incomplete muscle relaxant reversal or re-curarization may be associated with postoperative respiratory complications. In this retrospective study we compared the incidence of postoperative residual curarization and respiratory complications in association with the type of muscle relaxant reversal agent, sugammadex or neostigmine, in patients undergoing laparoscopic sleeve gastrectomy.

MATERIAL AND METHODS

We reviewed the charts of all patients (179) undergoing laparoscopic sleeve gastrectomy from July 2012 to July 2013 at Wolfson Medical Center. Sugammadex 1.5-2 mg/kg (112 patients) or neostigmine 2.5 mg (67 patients) were used as reversal agents. Results were compared by the type of reversal agent employed. Compared parameters included demographic and anaesthetic data, residual curarization, oxyhemoglobin saturation (SpO2) in the recovery room (PACU), episodes of SpO2 lower than 90% in PACU, unexpected intensive care (ICU) admissions, incidence of atelectasis and pneumonia, re-intubation and duration of hospitalization.

RESULTS

Obstructive sleep apnea syndrome (OSAS) was more frequent in the sugammadex group (19% vs. 8%; p = 0.026). Total intravenous anesthesia (TIVA) was more frequently associated with sugammadex (33% vs. 16%; p = 0.007). There were no differences in postoperative residual curarization, SpO2 < 90% episodes, reintubation, ICU admissions, pulmonary complications and duration of hospitalization.

CONCLUSION

With the inherent limitations of a retrospective study, the use of sugammadex following laparoscopic sleeve gastrectomy showed no advantage over neostigmine in terms of residual curarization and respiratory complications.

Transient neurological symptoms after isobaric subarachnoid anesthesia with 2% lidocaine: the impact of needle type

BACKGROUND

The reported incidence of transient neurological symptoms (TNS) after subarachnoid lidocaine administration is as high as 40%. We designed this clinical trial to determine the incidence of TNS with two different pencil-point spinal needles: one-orifice (Atraucan) and two-orifice (Eldor) spinal needles.

METHODS

Ninety-nine ASA physical status I or II patients undergoing surgical procedures of the urinary bladder or prostate were prospectively allocated to receive spinal anesthesia with 40 mg, 2% isobaric lidocaine plus fentanyl injected through either a 26-gauge Atraucan (n = 52) or a 26-gauge Eldor (n = 47) spinal needle. During the first three postoperative days, patients were observed for postoperative complications, including TNS. The primary end-point for this trial was the percentage of TNS in both double- and single-orifice spinal needle procedures.

RESULTS

The incidence of TNS was higher when spinal anesthesia was done through the Atraucan needle (28.8% vs 8.5%, P = 0.006). Fifty percent of the patients in the double-orifice group versus 100% of the single-orifice group developed TNS after surgery in the lithotomy position (P = 0.014). The relative risk for developing TNS with the Eldor needle was 0.29 (95% CI: 0.07-0.75) compared with the Atraucan needle.

CONCLUSIONS

The use of a double-orifice spinal needle was associated with a lower incidence of TNS, which may have been due to the needle design.

Association of ethnicity with the minimum alveolar concentration of sevoflurane

BACKGROUND

Selective breeding produces animal strains with varying anesthetic sensitivity. It thus seems unlikely that various human ethnicities have identical anesthetic requirements. Therefore, the authors tested the hypothesis that the minimum alveolar concentration of sevoflurane differs significantly as a function of ethnicity.

METHODS

The authors recruited 90 American Society of Anesthesiologists physical status I and II adult patients belonging to three Jewish ethnic groups: European, Oriental, and Caucasian (from the Caucasus Mountain region). All were scheduled to undergo surgery requiring a skin incision exceeding 3 cm. Without premedication, anesthesia was induced with 6-8% sevoflurane in 100% oxygen, and tracheal intubation was facilitated with succinylcholine. The skin incision was made after a predetermined end-tidal concentration of sevoflurane of 2.0% was maintained for at least 10 min in the first patient in each group. Blinded investigators observed the patient for movement during the subsequent minute. The concentration in the next patient was increased by 0.2% when patients moved, or decreased by the same amount when they did not. Results are presented as means [95% confidence intervals].

RESULTS

Morphometric and demographic characteristics were similar among the groups; however, mean arterial pressure was slightly greater in European Jews. Minimum alveolar concentration for sevoflurane was greatest in Caucasian Jews (2.32% [2.27-2.41%]), less in Oriental Jews (2.14% [2.06-2.22%]), and still less in European Jews (1.9% [1.82-1.99%]) (P < 0.001).

CONCLUSIONS

The results suggest that minimum alveolar concentration varies as a function of ethnicity. However, the extent to which confounding characteristics contribute, including lifestyle choices and environmental factors, remains unknown.

Predistention of the Epidural Space Before Catheter Insertion Reduces the Incidence of Intravascular Epidural Catheter Insertion

BACKGROUND

Accidental cannulation of an epidural vein is a common complication associated with epidural anesthesia or analgesia. On the basis of a pilot study and previous reports, we tested the hypothesis that predistention of the epidural space with saline before epidural catheterization would ease catheter insertion and decrease the incidence of this complication.

METHODS

Two-hundred-three laboring women were randomly assigned to receive an epidural with loss of resistance technique with 2 mL (nondistention) or 5 mL saline (distention). In the distention group, the syringe plunger was held closed before epidural catheter insertion. Then in both groups, a test dose of 3 mL of 1.5% lidocaine was injected through the epidural catheter.

RESULTS

There were fewer accidental intravascular catheter placements (2% vs 16%, P = 0.0001) in the distention group, and 91% of patients in this group did not have any unblocked segments versus 67% in the nondistension group (P = 0.0001). The difference in onset time of analgesia was small (5.0 +/- 2 min vs 6 +/- 3 min, P = 0.0001) and not clinically important. The quality of analgesia (visual analog scores and ropivacaine consumption) was similar between groups.

CONCLUSIONS

Distention of the epidural space with 5 mL saline before epidural catheter insertion decreased the incidence of accidental venous cannulation and the number of unblocked segments.

Options for systemic labor analgesia

PURPOSE OF REVIEW

This article reviews the challenging practice of systemic analgesia as an alternative to epidural analgesia for labor pain, and places remifentanil within the context of opioid analgesics suitable for managing for labor pain.

RECENT FINDINGS

Although systemic opioids have long been used for labor analgesia, they have become less popular because of frequent maternal and neonatal side effects. Recently, their efficacy has been questioned. Patient-controlled intravenous analgesia with fentanyl or sufentanil is currently the method of choice for achieving analgesia during early labor, when epidural analgesia is not feasible. Remifentanil has been suggested as the opioid of choice for labor analgesia, having the advantage of easy administration, predictable pharmacokinetics, and improved neonatal outcomes. The position of remifentanil in obstetric analgesia is now better understood, as reflected by the increasing number of reported studies describing its use.

SUMMARY

Remifentanil is now gaining popularity. Remifentanil may be more suitable than other traditional opioids for inducing labor analgesia. Careful monitoring of the parturient and the newborn is recommended, however, to mitigate the potential for maternal and neonatal hypoxemia.

Activin βA in term placenta and its correlation with placental inflammation in parturients having epidural or systemic meperidine analgesia: a randomized study

STUDY OBJECTIVE

To investigate the immunohistochemical localization of betaA subunit of activin A in human term placenta, as a marker for placental infection/inflammation and elevated temperature, in parturients laboring during two analgesic regimens.

DESIGN

Prospective, randomized controlled study.

SETTING

Delivery room.

PATIENTS

56 healthy, ASA physical status I and II primiparous women in labor.

INTERVENTIONS

Parturients were assigned to receive patient-controlled epidural analgesia (PCEA) with 0.2% ropivacaine or patient-controlled intravenous analgesia PCA with meperidine.

MEASUREMENTS

Histologic and immunohistochemical placental evaluation for white blood cell infiltration and activin betaA staining were made. Maternal temperature elevation above 37.6 degrees C and leukocytosis above 15,000/microL were recorded.

MAIN RESULTS

Temperature was not significantly increased in parturients receiving PCEA over those who received (PCA) with meperidine (31% vs 11%, respectively; P = 0.1). There was also no association between temperature elevation during epidural analgesia and increased white blood cell count (>15,000/microL) or presence of polymorphonuclear and/or lymphocyte aggregation in the placenta. Immunohistochemical staining with antisera against the betaA subunit of activin was present mainly in the placental cytotrophoblast, syncytiotrophoblast, and vascular endothelium, and was not associated with an increase in maternal temperature. No significant difference was noted between the two analgesic techniques with regard to maternal temperature elevation. Intrapartum temperature elevation was not associated with histologic signs of placental inflammation or with expression of activin betaA in the placenta.

CONCLUSION

Other mechanisms may be involved in the etiology of temperature elevation during labor.

Proper insertion depth of endotracheal tubes in adults by topographic landmarks measurements

STUDY OBJECTIVE

To evaluate a new method of endotracheal tube (ETT) positioning relative to carina, based on external topographic landmarks.

DESIGN

Prospective, randomized, crossover study.

SETTING

Operating room, university hospital.

PATIENTS

200 American Society of Anesthesiologists (ASA) physical status I-II patients (100 women and 100 men) scheduled for elective surgery with general anesthesia.

INTERVENTIONS

ETT insertion depth was topographically determined by adding the distance measured (in cm) from the right mouth corner to right mandibular angle to the distance measured from the right mandibular angle to a point situated on the center of a line running transversally through the middle of the sternal manubrium. This method was compared to the 21/23 cm insertion depth method.

MEASUREMENTS

ETT position was assessed fiberoptically. The main end point was considered the percentage of ETT tips situated more than 25% higher or lower than a predetermined "best" tip position (4 cm above the carina).

MAIN RESULTS

There were 58.5% ETT tips positioned too closely (<3 cm above the carina) to the carina with the control method and 24% with the study method (P=0.0001). No ETT tip was too high (>5 cm above the carina). The tip-carina distance was shorter in women (2.7+/-2.5 vs 3.6+/-2.2 cm in men P=0.0001) and in those aged more than 65 years (2.8+/-2.4 vs 3.4+/-2.4 cm with age less than 65 years; P=0.012) only with the 21/23 cm method.

CONCLUSIONS

With our new ETT positioning method, there were fewer ETTs positioned outside the desired range of distance to carina. Our method may be especially valuable in women and in patients older than 65 years.

The importance of blood sampling site for determination of hemoglobin and biochemistry values in major abdominal and orthopedic surgery

STUDY OBJECTIVE

To determine whether sampling of blood from different sites influences laboratory results.

DESIGN

Prospective, double-blind study.

SETTING

University-affiliated hospital in Israel.

PATIENTS

100 ASA physical status I, II, and III patients undergoing major orthopedic or colon surgery (total hip and revision of total hip replacement, colon resection, or radical cystectomy).

MEASUREMENTS

Blood was sampled simultaneously for hemoglobin, electrolytes, glucose, pH, blood gases, and lactate from three sampling sites (peripheral vein, central vein, and radial artery) at 5 time frames (after induction of anesthesia [baseline], one hr after induction of anesthesia, at the end of surgery, after one hr in the recovery room, and 4 hrs after surgery). At the same time points, recorded rectal temperature, mean arterial pressure, heart rate, and central venous pressure were recorded. Anesthesia, monitoring, and dwell volumes before sampling were standardized.

MAIN RESULTS

There were no significant differences between the results of hemoglobin, electrolytes, glucose, pH, and blood gases obtained from different sampling sites and at different time frames. Lactate level (mmol/L) was higher in peripheral venous blood than it was in either the central vein or radial artery (<0.05), and higher in central venous blood compared with arterial blood (P < 0.05; 2.04 +/- 1.16, 1.74 +/- 0.78, and 1.54 +/- 0.68, respectively).

CONCLUSION

Under stable hemodynamics and in the absence of hypothermia, serum lactate level was higher in peripheral venous blood than it was in the central vein or radial artery.

The outcome of preterm neonates with intraventricular hemorrhage delivered with intravenous meperidine or epidural analgesia

We aimed to study, retrospectively, the neonatal outcome of 45 preterm neonates with intraventricular hemorrhage (IVH) who were delivered vaginally with intravenous meperidine (n = 23) or epidural analgesia (n = 22). Neonates in the epidural group had a better outcome in terms of a first-minute Apgar score of 7 or less, in 31% vs 69% (P = 0.001); 5-min Apgar score of 7 or less, in 18% vs 82% (P = 0.003); a lower incidence of respiratory distress syndrome (RDS; 23% vs 30%; P = 0.03); a lower dopamine requirement during the first neonatal week (13% vs 72%; P = 0.01); and a higher survival rate (91% vs 58%, respectively; P = 0.008). It is concluded that preterm neonates with IVH had a better outcome when delivered to mothers receiving epidural analgesia as compared to those receiving intravenous meperidine.

Pregnancy-associated rhinitis

Previous studies overestimated the incidence of pregnancy-associated rhinitis because it is a poorly defined clinical condition. The objective of this study was to assess the incidence of this unique type of rhinitis using up-to-date strict criteria. This prospective study included 109 primigravida parturients who were interviewed using a structured questionnaire and underwent detailed rhinoscopy. Pregnancy-associated rhinitis was defined as nasal obstruction symptom and rhinorrhea appearing during pregnancy, lasting for at least 2 months, and disappearing postpartum. The incidence of rhinitis associated with pregnancy at the time of delivery was 9%. No correlation was found between symptoms and signs. Pregnancy-associated rhinitis is an infrequent clinical entity. It may be related to hormonal changes and possibly altered sensation of nasal airflow.

Correct depth of insertion of right internal jugular central venous catheters based on external landmarks: avoiding the right atrium

OBJECTIVE

Radiographically, a central venous catheter (CVC) tip should lie at the level of the right tracheobronchial angle. Precalculation of length of CVC insertion may avoid unnecessary catheter malposition. The purpose of this study was to assess the accuracy of a method of CVC positioning, based on external topographic landmarks.

DESIGN

A prospective, randomized study.

SETTING

University-affiliated hospital, single institution.

PARTICIPANTS

Patients scheduled for surgery.

INTERVENTIONS

Patients were allocated for insertion of the catheter through the right internal jugular vein to either a fixed, predetermined, 15-cm length (n = 50) or to a depth calculated topographically (n = 50) by drawing a line from the level of the thyroid notch to the sternal manubrium. The catheter was repositioned if its tip was situated >5 cm above the carina or >1 cm below it. The distance from the catheter tip to the carina was measured. The main study endpoint was the need for catheter repositioning.

MEASUREMENTS AND MAIN RESULTS

Two percent of patients required repositioning in the topographic group compared with 78% in the 15-cm length group (p < 0.001). No patient in the topographic group and 10 patients (20%) in the 15-cm group had the catheter placed in the right atrium (p < 0.05). The mean distance from the CVC tip to the carina was 2.9 +/- 1.4 cm above the carina in the topographic group and 1.9 +/- 1.1 cm below the carina in the 15-cm length group (p < 0.001). No patient had a too proximally placed catheter. Insertion lengths in the topographic group ranged between 9 and 12.5 cm.

CONCLUSIONS

It is recommended to use the topographic approach in deciding CVC depth with right internal jugular CVC placement.

Patient-controlled epidural analgesia: the role of epidural fentanyl in peripartum urinary retention

BACKGROUND

Urinary bladder function is impaired during labor and delivery, predisposing to urinary retention. The effect of low-dose epidural opioid on bladder function remains unclear. We tested the hypothesis that adding low-dose fentanyl to epidural ropivacaine for patient-controlled labor analgesia does not promote urinary retention.

METHODS

Laboring women who requested patient-controlled epidural analgesia were randomly assigned in a double blind study to 0.2% ropivacaine (R-group, n=100) or 0.2% ropivacaine with fentanyl 2 microg/mL (RF-group, n=98). Urinary bladder distension was assessed clinically every hour. The post-void residual urine volume was measured by ultrasonography. Urine volume exceeding 100 mL was drained by catheterization. Bladder volume of > or =300 mL, as determined by catheterization was considered as evidence of urinary retention.

RESULTS

Thirty percent of the patients in each group developed urinary retention during labor. There was no statistically significant difference between the groups. There was an excellent correlation between bladder volume as estimated by ultrasonography and that by catheterization: catheterization volume=0.93 x ultrasound volume + 25; r(2)=0.83. The bias (mean error) was -1+/-99 mL and the precision (average absolute error) between the ultrasound estimate and actual bladder volume determined by catheterization was 58+/-79 mL.

CONCLUSION

Addition of fentanyl to patient-controlled epidural analgesia did not increase the risk of urinary retention. Ultrasound measurements were effective and reliable in assessing urinary bladder volumes during labor.

Morbidly obese patients are hemodynamically stable during laparoscopic surgery: a thoracic bioimpedance study

PURPOSE

Morbid obesity caries an increased risk of cardiovascular morbidity and might be associated with intraoperative hemodynamic instability. Based on clinical observation, we hypothesized that during laparoscopic surgery, morbidly obese patients behave hemodynamically similar to the nonobese patients and remain hemodynamically stable.

METHODS

In a prospective trial, thirty nonobese and tthirty morbidly obese (BMI > or = 35 kg/m(2)) patients scheduled for elective laparoscopic surgery were assigned to receive standard balanced anesthesia. We aimed at equianesthetic levels by keeping the BIS (bispectral index) value between 40-50 throughout surgery. End-tidal isoflurane was measured every 5 min. Noninvasive hemodynamic measurements included cardiac index (CI), mean arterial pressure (MAP) and heart rate (HR), recorded every 5 min and at specific predetermined times. Systemic vascular resistance (SVR) was calculated. Episodes of MAP < or = 60 and MAP > or = 130 mmHg or HR < or = 50 and HR > or = 110 bpm occurring throughout surgery and requiring pharmacological intervention were considered main end-points. Additionally, hemodynamic variables were compared at specific time points and overall throughout surgery. Secondary end-points were CI and SVRI.

RESULTS

Heart rate was higher in obese patients in head-up position (79 +/- 15 mmHg vs. 65 +/- 12 mmHg - P=0.011). SVR was higher in the nonobese group with head-up position (1978 +/- 665 dynes s cm(-5) vs. 1394 +/- 496 dynes s cm(-5) P=0.01). Mean overall intraoperative MAP, HR, CI and SVR were similar. There were no episodes of MAP < or = 60 and > or =130 mmHg or HR < or = 50 and > or =110 bpm in either of the groups.

CONCLUSION

Our study confirmed our hypothesis that for the most periods of laparoscopic surgery, obese patients are hemodynamically as stable as their nonobese counterparts.

Comparison of hemodynamic profiles in transurethral resection of prostate vs transurethral resection of urinary bladder tumors during spinal anesthesia: a bioimpedance study

STUDY OBJECTIVE

Transurethral resection of prostate (TURP) is more frequently associated with perioperative fluid and electrolyte disturbances than transurethral resection of bladder tumors (TURT) because of irrigating fluid absorption. Because fluid overload may cause hypertension, we compared the patients' intraoperative hemodynamic profiles (including the incidence of hypertension) during TURP vs TURT, both performed during spinal anesthesia, by using the bioimpedance method.

DESIGN

Prospective single-blind study.

SETTING

University hospital.

PATIENTS

80 (40 in each group) men, ASA physical status I and II.

INTERVENTIONS

Patients underwent TURP or TURT surgery with spinal anesthesia.

MEASUREMENTS

Mean arterial pressure, heart rate, cardiac index, and systemic vascular resistance were compared between the 2 groups. A mean arterial pressure greater than 30% from the baseline value was considered as hypertension. Plasma sodium was measured preoperatively, intraoperatively, and postoperatively.

MAIN RESULTS

Transurethral resection of prostate patients received more irrigating fluid (7900 +/- 2310 vs 5650 +/- 21560, P < 0.05) and had a higher calculated volume of fluid absorbed: 638 +/- 60 vs 303 +/- 40 mL for the TURT patients (P < 0.05). Mean arterial pressures were higher with TURP, 30 minutes after the onset of surgery and at the end of the procedure (111 +/- 15 vs 100 +/- 10 and 109 +/- 14 vs 99 +/- 14 mmHg, respectively; P < 0.05). However, there was no hypertension in either group. There were no differences in hemodynamic measurements of hyponatremic vs normonatremic patients. Plasma sodium decreased postoperatively more in the TURP group (140.4 +/- 2.6 mEq/L baseline to 134.1 +/- 3.5 mEq/L, P < 0.05) and was lower postoperatively in the TURP group compared with TURT (134.1 +/- 3.5 vs 137.2 +/- 2.9 mEq/L, P = 0.04).

CONCLUSIONS

Although more irrigating fluid was absorbed in the TURP group, there were no episodes of hypertension in either group.

Similar incidence of hypotension with combined spinal-epidural or epidural alone for knee arthroplasty

BACKGROUND

We hypothesized that the incidence of hypotension during total knee replacement (TKR) surgery is lower in patients given combined spinal-epidural (CSE) anesthesia vs those receiving epidural anesthesia alone.

METHODS

In a prospective study, 80 American Society of Anesthesiologists I-II patients (aged 40-80 yr), undergoing elective TKR surgery were randomly assigned to either CSE anesthesia (CSE, n = 40) or epidural anesthesia alone (Epidural, n = 40). Hemodynamic measurements included oscillometric mean arterial blood pressure (MAP), heart rate (HR), and cardiac index (CI) as determined by thoracic bioimpedance; systemic vascular resistance (SVR) was calculated. Our primary endpoint (outcome) was the number of hypotension episodes (defined as MAP < 70 mmHg).

RESULTS

Using univariate analysis, we found no differences between the groups in regards to MAP, HR, CI, or SVR during the perioperative period. The incidence of hypotension was similar in both groups (two patients in each group), as was the incidence of bradycardia (12 patients in CSE, 7 in Epidural; P = 0.2). There were no differences between groups in other hemodynamic measurements including CI and calculated SVR. Analgesia supplementation with fentanyl was more frequently required in the Epidural group (20 vs 6 patients - P = 0.03).

CONCLUSION

Combined spinal-epidural anesthesia and epidural anesthesia alone during TKR surgery are associated with the same incidence of hypotension with statistically and clinically similar hemodynamic responses.

[Tracheostomy and endotracheal intubation: a short history]

The first descriptions of tracheostomy appear in old Hindu scripts around 2000 BC and Egyptian documents around 1500 BC. Since then, other reports in animals and humans established the tracheostomy as a life saving procedure. Vesalius in 1543 reported the first tracheal intubation in an animal. Trousseau reported 200 patients suffering from diphtheria who were saved by tracheostomy. In the early 1870's, Trendelenburg from Germany performed the first endotracheal anesthesia in man. Macewen in 1878 reported the first elective endotracheal intubation for anesthesia. He isolated the trachea by packing the hypopharynx, from leaking of blood and debris. Later, Rosenberg and Kuhn administered cocaine as local anesthetic to obtund the cough reflex during intubation. Tracheostomy and intubation have been broadly used during the First World War. Magill (1888-1986) recognized the advantages of tracheal intubation. Also, by his efforts, anesthesia has become an independent specialty. In 1913 the first anesthetic laryngoscope was invented by Jackson and modified by the Magill, Miller and Macintosh. In 1942, curare was introduced as a muscle relaxant for abdominal relaxation during general anesthesia and endotracheal intubation became routine in major abdominal and other surgeries. The article also reviews the Israeli contribution to the development of tracheostomy.

The effects of an external nasal dilator on labor

BACKGROUND

The aim of this study was to assess the effect of an external nasal dilator on several variables characterizing labor in both mother and fetus.

METHODS

One hundred and fifty primigravida women in active labor were randomized to wear, throughout labor, either a dilator spring-loaded nasal strip or a placebo device. Data were obtained during labor and compared between the groups. After delivery, the satisfaction rate was assessed.

RESULTS

No differences were found between the study and the control group regarding rate of induction or augmentation of labor as well as Montevideo units reached, frequency of rupture of membranes, duration of the active phase and second stage of labor, usage of epidural analgesia, normal fetal heart pattern, meconium-stained amniotic fluid, and neonatal well being. Length of maternal and neonatal hospitalization also did not differ between the groups. Satisfaction rate was significantly higher in parturient women wearing nasal strips with a dilator spring than in parturient women wearing a placebo spring (P < 0.0001).

CONCLUSION

Nasal strips do not change the course but ameliorate the quality of labor by improving the ease of breathing. Nasal dilators sustain the respiratory effort associated with the long process of labor and may control the switch from nasal to oronasal breathing during delivery.

Remifentanil: A Novel Systemic Analgesic for Labor Pain

In a double-blind, randomized, controlled clinical trial, we compared the analgesic effect of remifentanil in patient-controlled IV analgesia (PCIA) during labor and delivery with the effect of an IV infusion of meperidine. Eighty-eight healthy term parturients who requested IV analgesia for labor pain were enrolled in the study and were randomly assigned to receive either increasing doses (0.27-0.93 microg/kg per bolus) of PCIA remifentanil (n=43) or an IV infusion of meperidine 150 mg (range, 75-200 mg) per patient (n=45). Remifentanil by the PCIA device was more effective and reliable analgesia for labor and delivery than IV infusion of meperidine. The visual analog score was lower (35.8 +/- 10.2 versus 58.8 +/- 12.8; P <0.001) and the patient satisfaction score higher (3.9 +/- 0.6 versus 1.9 +/- 0.4; P <0.001), with less of a sedative effect (1.2 +/- 0.1 versus 2.9 +/- 0.1; P <0.001) and less hemoglobin desaturation (97.5% +/- 1.0 versus 94.2% +/- 1.5; P <0.007). The percentage of analgesia failure (the rate of crossover from opiate to epidural analgesia) was less for remifentanil compared with meperidine (10.8% versus 38.8%; P <0.007). There were no significant differences between groups in the mode of delivery or neonatal outcome. There were fewer nonreassuring abnormal fetal heart rate patterns, i.e., higher variability and reactivity with fewer decelerations, under remifentanil therapy as compared with meperidine (P <0.001). In conclusion, an intermittent incremental regimen with repeated small-dose PCIA boluses of remifentanil provided effective and reliable analgesia during labor and delivery.

Nasal versus oral fiberoptic intubation via a cuffed oropharyngeal airway (COPA™) during spontaneous ventilation

STUDY OBJECTIVE

To compare the success rate of nasal versus oral fiberoptic intubation in anesthetized patients breathing spontaneously via the cuffed oropharyngeal airway (COPAtrade mark).

DESIGN

Prospective, randomized, controlled study.

SETTING

Two university-affiliated hospitals.

PATIENTS

Patients scheduled for general or plastic surgery of the torso or extremities.

INTERVENTIONS

Nasal (n=20) and oral (n=20) fiberoptic intubation were performed in patients while breathing spontaneously via the COPA during standardized anesthesia.

MEASUREMENTS

Demographic data, mean arterial pressure, heart rate, end-tidal carbon dioxide (ETCO2), oxygen saturation (SpO2), COPA size, difficult airway predictors, rate of failed ventilation via COPA, and frequency of hypoxemia (SpO2 < 90%) during the procedure, and perioperative untoward events were recorded.

MAIN RESULTS

The background, airway difficulty, vital signs and untoward effects were similar in the two groups. Nasal fiberoptic laryngeal view (scale 1-4) was better than the oral grading (3 [median] vs. 2, respectively; p <0.05). Eighty percent of the nasal intubations were successful compared with 40% of the oral intubations (p <0.05). Nasal intubations were accomplished within 153 +/- 15 SD seconds compared with 236 +/- 22 seconds (p <0.05) for the oral intubations, and less propofol was needed in the nasal intubations during the procedures (240 +/- 27 mg [nasal] vs. 277+/- 39 mg [oral]; p <0.05).

CONCLUSIONS

Nasal fiberoptic laryngoscopy is more successful and easy than the oral approach in anesthetized patients who are breathing spontaneously through the COPA.

Patient-controlled epidural analgesia for labor pain: effect on labor, delivery and neonatal outcome of 0.125% bupivacaine vs 0.2% ropivacaine

The objective was to evaluate the influence of patient-controlled epidural analgesia (PCEA) using low doses of bupivacaine vs. ropivacaine, on labor pain, motor blockade, progression of labor, delivery and neonatal outcome. This randomized double blind study included 565 parturients. All received a 5-mL/h infusion and PCEA (5-mL boluses with a 20-min lockout, maximum volume 20 mL/h) of either 0.125% bupivacaine (n = 313: 165 nulliparous, 148 parous) or 0.2% ropivacaine (n = 252: 113 nulliparous, 139 parous). Pain score, lower limb motor block, sensory levels, local analgesic doses required, hemodynamic parameters, side effects and complications were assessed. Obstetric variables included cervical dilation at epidural insertion, incidence of ruptured membranes and their duration, use of oxytocin, fetal heart rate changes, duration of labor, mode and outcome of delivery, and use of invasive and non-invasive fetal monitoring. Neonatal characteristics included birth weight, Apgar scores, umbilical artery pH, serum bilirubin, hypoglycemia, need for assisted ventilation, sepsis or sepsis study, feeding difficulties and respiratory distress syndrome. Ropivacaine 0.2% was equianalgesic with 0.125% bupivacaine, but produced less motor block (P < 0.0001). There were no significant differences, however, in duration of labor, delivery type or neonatal outcome.

Role of sonography in the diagnosis of retained products of conception

OBJECTIVE

To present our experience with clinical and sonographic diagnosis of retained products of conception and to evaluate its correlation with histopathologic findings.

METHODS

This was a retrospective study on 156 patients admitted for retained products of conception. Women were referred because of 1 or more of the following: abdominal pain, bleeding, and fever. The status of the cervix was evaluated by bimanual examination. The diagnosis of retained products of conception was made when a sonographic finding of hyperechoic or hypoechoic material was seen in any part of the uterine cavity or the presence of a thickened endometrial stripe greater than 8 mm and an irregular interface between the endometrium and myometrium was found. One hundred twenty-one women (77.6%) were admitted after dilation and curettage for abortion, and 35 (22.4%) were admitted after spontaneous labor.

RESULTS

Histopathologic reports confirmed the diagnosis of retained products of conception in 86 (71%) of 121 women in the postabortion group and in 17 (48.5%) of 35 women in the postpartum group. The overall false-positive rate for sonographic diagnosis was 34%. For women after abortion and after delivery, the false-positive rates were 28.9% and 51.5%, respectively.

CONCLUSIONS

Reliance on common signs and symptoms to diagnose retained products of conception as well as the use of sonography is associated with an unacceptably high false-positive rate, mainly after delivery. A more conservative approach to the treatment of retained products of conception is suggested.

Human Immunodeficiency Virus: Anesthetic and Obstetric Considerations

The pandemic of acquired immune deficiency syndrome (AIDS) is on the threshold of its third decade of existence. The World Health Organization-United Nations statistics show that human immunodeficiency virus (HIV)/AIDS pandemia is set to get much worse. Women of reproductive age are the fastest growing population with HIV. Common signs and symptoms have become more moderate or subclinical, and new clinical presentations have emerged. It is quite apparent that HIV-disease affects multiple organ systems. Advances have been made in elucidating the pathogenesis of HIV. In addition, the molecular technique of viral load determination and the CD + 4 T-lymphocyte count enable evaluation of the disease, its prognosis, and its response to therapy. There is limited specific information concerning the overall risk of anesthesia and surgery of HIV/AIDS patients. However, as far as can be determined, surgical interventions do not increase the postoperative risk for complications or death and should therefore not be withheld. There is also little evidence to suggest that HIV or antiretroviral drugs increase the rate of pregnancy complications or that pregnancy may alter the course of HIV infection. General anesthesia is considered safe, but drug interactions and their impact on various organ systems should be considered preoperatively. Regional anesthesia is often the technique of choice. Yet, one must take into consideration the presence of neuropathies, local infection, or blood clotting abnormalities. It should be emphasized that all practicing anesthesiologists should be familiar with the disease and should use prenatal anesthesia consultations and a team approach to assure optimal treatment for HIV patients.

Current understanding of the patient's attitude toward the anesthetist's role and practice in Israel: effect of the patient's experience

STUDY OBJECTIVE

To assess the patient's understanding and knowledge of the anesthesiologist's role and responsibilities in the operating room and in other areas of hospital activity, and to delineate the effect of previous anesthetic experience on this knowledge.

DESIGN

Prospective study consisting of standard preanesthetic interview and questionnaire survey.

SETTING

Preoperative anesthetic clinic in a large central private hospital in Israel.

PATIENTS

295 adult patients who were seen in the preanesthetic clinic in a 4-week period in May, 2000.

INTERVENTIONS

After patients were checked for exclusion criteria and given a standard preanesthetic interview, all adult patients presenting to this clinic were asked to participate in the study and complete a questionnaire, which was later evaluated statistically.

RESULTS

A total of 295 patients (90% response rate) took part in the study. Two hundred (67.8%) patients had previous experience with anesthetics (Group A), and 95 (32.2%) patients presented for the first time for anesthesia (Group B). Ninety-five percent in Group A and 94.7% of Group B believed that the anesthesiologist is a doctor. Ninety-three percent of Group A and 90.5% of Group B answered that the anesthesiologist himself administered the anesthetic drugs. As to the responsibility for the patient's well-being during the operation and postoperatively, opinion was divided equally as to whether the surgeon or the anesthesiologist is responsible. The patients in both groups seemed to be well informed about the way anesthetic drugs act. Only 4% of patients of both groups knew about the anesthesiologist's other duties outside the operation room.

CONCLUSION

If able to be extrapolated to all of Israel, our results show a high appreciation for the physician status of the anesthesia professional and role in safe recovery. Passive learning from a prior anesthetic experience did not appear to improve such appreciation.

[Intravenous regional anesthesia in patients with hypokalemic periodic paralysis]

Hypokalemic periodic paralysis is a familial autosomal dominant trait. The paralytic attacks are precipitated by large carbohydrate-rich meals, cold, mental or surgical stress, infections, exercise, drugs, electrolytes and endocrine abnormalities. Death may occur from respiratory arrest, infections, aspiration or cardiac arrhythmias. Anesthesia and surgical procedures may induce an attack and complicate the perioperative patient condition. Guidelines for anesthetic management should include preventive measures i.e. reduce mental stress and carbohydrate intake and correction of electrolytes and endocrine abnormalities. During the operation, measures should include prevention of cold and monitoring of muscle relaxants and ECG. When paralysis is diagnosed, slow (50 mEq/hr) i.v. infusion of potassium is suggested, while monitoring plasma levels of potassium ECG, and facial nerve conduction. We present two patients with hypokalemic periodic paralysis who underwent uneventful orthopedic procedures under i.v. regional block.

Intracranial subdural hematoma following dural puncture in a parturient with HELLP syndrome

PURPOSE

To present a case of postpartum bilateral intracranial subdural hematoma after dural puncture during attempted epidural analgesia for labour.

CLINICAL FEATURES

This complication occurred following accidental dural puncture in a parturient with thrombocytopenia (99,000 x microL-1) who subsequently developed the syndrome of hemolysis, elevated liver enzymes and low platelets. On the first postoperative day, postdural puncture headache (PDPH) developed. An epidural blood patch (EBP) was deferred to the third postoperative day because of a platelet count of 21,000 x micro L-1. However, the headache intensified from a typical PDPH to one which was not posturally related. A second EBP was abandoned after the injection of 5 mL of blood because of increasing headache during the procedure. Magnetic resonance imaging revealed bilateral temporal subdural hematomas. The patient was managed conservatively and discharged home without any sequelae.

CONCLUSION

It is conceivable that thrombocytopenia together with possible abnormal platelet function increased the risk of subdural hematoma. Alternative diagnoses to PDPH should be considered whenever headache is not posturally related.

Postoperative nausea and vomiting: comparison of the effect of postoperative meperidine or morphine in gynecologic surgery patients

STUDY OBJECTIVE

To evaluate the incidence and severity of postoperative nausea and vomiting in women receiving postoperative intravenous morphine or meperidine following gynecologic surgery.

DESIGN

Prospective, double-blind, randomized study.

SETTING

Tertiary-care academic medical center.

PATIENTS

200 ASA physical status I, II, and III patients scheduled for elective gynecologic surgery.

INTERVENTIONS

Patients received either postoperative IV morphine (n = 100) or meperidine (n = 100) following gynecologic surgery.

MEASUREMENTS

We compared pain scores, sedation scores, nausea scores, well-being scores, vomiting rate, and patient satisfaction in both groups 15, 30, 60, and 120 minutes after arrival in the postoperative anesthesia care unit.

MAIN RESULTS

The vomiting rate was 8/100 versus 7/100 (at 15 min), 4/100 versus 26/100 (at 30 min) (p < 0.05), 3/100 versus 23/100 (at 60 min) (p < 0.05), and 0/100 versus 0/100 (at 120 min) in the morphine or meperidine groups, respectively. The pain and sedation scores were similar in both groups. No major complications were noted in either group.

CONCLUSION

Our study demonstrates an advantage of the use of morphine rather than meperidine for pain control in the immediate postoperative period following gynecologic surgery.

[The management of HIV patients during surgery and in the delivery ward: anesthetic considerations]

To date a total of more than 50 million individuals worldwide have been infected with HIV and more than 20 million have died from the disease. Two thirds of the known carriers of HIV 36 million worldwide, live in Africa. In Israel, as of December 31, 2000, there are a total of 2,843 reported carriers and 165 persons alive with AIDS. On the basis of future projections of increasing incidence of HIV/AIDS in obstetric patients undergoing anesthesia and surgery, obstetricians and anesthesiologists should be aware of the disease and its impact on anesthetic techniques and possible interactions between anesthetic drugs and HIV therapeutic agents. Surgical staff members should be knowledgeable and updated concerning safety precautions during surgical and anesthetic procedures.

Difficult airway in obstetric anesthesia: a review

Failed intubation and ventilation are important causes of anesthetic-related maternal mortality. The purpose of this article is to review the complex issues in managing the difficult airway in obstetric patients. The importance of prompt and competent decision making in managing difficult airways, as well as a need for appropriate equipment is emphasized. Four case reports reinforce the importance of a systematic approach to management. The overall preference for regional rather than general anesthesia is strongly encouraged. The review also emphasizes the need for professional and experienced team cooperation between the obstetrician and the anesthesiologist for the successful management of these challenging cases.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to break down the complex issues in managing the difficult airway in the obstetric patient, outline the reasons for difficult intubations in pregnancy, and describe the evaluation used to predict a difficult intubation.

Oligohydramnios: maternal complications and fetal outcome in 145 cases

One hundred and forty-five cases of oligohydramnios in the second and third trimester were diagnosed by ultrasonography out of 25,000 obstetrics patients (0.58%). In this group, pregnancy complications included hypertension (22.1%) and bleeding in the second trimester (4.1%). We found a high incidence of meconium-stained amniotic fluid (29.1%), fetal distress (7.9%) and premature placental separation (4.2%). IUGR occurred in 24.5% of cases. Asphyxia during labor occurred in 11.5% and different other perinatal problems in 23.5%. Cesarean section was performed in 35.2% of these pregnancies. Seventeen percent of the cases presented as breech. Intrauterine fetal death occurred in 5.5% of these pregnancies. The gross perinatal mortality was 16% and the corrected perinatal mortality was 10.7%. The overall rate of fetal malformations was 11% and that of lethal malformations 4.8%. The skeletal (7.6%) and urinary system (4.1%) were the predominant systems affected. Oligohydramnios is associated with a higher rate of pregnancy complications and increased fetal morbidity and mortality, and thus termination should be considered when pulmonary maturity is present or in cases of fetal distress.