Assessing introduction of spinal anaesthesia for obstetric procedures.
To assess the impact of introducing spinal anaesthesia for obstetric operative procedures on use of general anaesthesia and quality of regional anaesthesia in a unit with an established epidural service a retrospective analysis of routinely collected data on method of anaesthesia, efficacy, and complications was carried out. Data were collected from 1988 to 1991 on 1670 obstetric patients requiring an operative procedure. The introduction of spinal anaesthesia in 1989 significantly reduced the proportion of operative procedures performed under general anaesthesia, from 60% (234/390) in 1988 to 30% (124/414) in 1991. The decrease was most pronounced for manual removal of the placenta (88%, 48/55 v 9%, 3/34) and emergency caesarean section (67%, 129/193) v 38%, 87/229). Epidural anaesthesia decreased in use most significantly for elective caesarean section (65%, 77/118 v 3% 3/113; x2=139, p<0.0001). The incidence of severe pain and need for conversion to general anaesthesia was significantly less with spinal anaesthesia (0%, 0/207 v 3%, 5/156; p<0.05). Hypotension was not a problem, and the incidence of headache after spinal anaesthetic decreased over the period studied. Introducing spinal anaesthesia therefore reduced the need for general anaesthesia and improved the quality of regional anaesthesia. (+info)
Anaesthesia for caesarean section in the presence of severe primary pulmonary hypertension.
We describe the case of a pregnant woman, 35 weeks' gestation, with primary pulmonary hypertension and coarctation of the aorta requiring emergency Caesarean section under general anaesthesia. The patient had a pulmonary artery catheter inserted before operation which revealed pulmonary artery pressures in excess of 80/40 mm Hg. These were lowered using an infusion of glyceryl trinitrate. After delivery of the baby and administration of oxytocin, pulmonary artery pressures were more difficult to control. An infusion of prostacyclin was substituted which stabilized pulmonary pressures. After operation, she was transferred to the intensive care unit where prostacyclin was administered by an "aerosolized" route. Her trachea was extubated after 48 h and she made an uneventful recovery. (+info)
Anaesthetic management of a woman who became paraplegic at 22 weeks' gestation after a spontaneous spinal cord haemorrhage secondary to a presumed arteriovenous malformation.
A 19-yr-old woman developed a paraplegia with a T10 sensory level at 22 weeks' gestation. The spinal injury was caused by spontaneous bleed of a presumed arteriovenous malformation in the spinal cord. She presented for Caesarean section at term because of the breech position of her fetus. The successful use of a combined spinal epidural-regional anaesthetic is described and the risks of general and regional anaesthesia are discussed. (+info)
Spinal versus epidural anesthesia for cesarean section in severely preeclamptic patients: a retrospective survey.
BACKGROUND: Selection of spinal anesthesia for severely preeclamptic patients requiring cesarean section is controversial. Significant maternal hypotension is believed to be more likely with spinal compared with epidural anesthesia. The purpose of this study was to assess, in a large retrospective clinical series, the blood pressure effects of spinal and epidural anesthesia in severely preeclamptic patients requiring cesarean section. METHODS: The computerized medical records database was reviewed for all preeclamptic patients having cesarean section between January 1, 1989 and December 31, 1996. All nonlaboring severely preeclamptic patients receiving either spinal or epidural anesthesia for cesarean section were included for analysis. The lowest recorded blood pressures were compared for the 20-min period before induction of regional anesthesia, the period from induction of regional anesthesia to delivery, and the period from delivery to the end of operation. RESULTS: Study groups included 103 women receiving spinal anesthesia and 35 receiving epidural anesthesia. Changes in the lowest mean blood pressure were similar after epidural or spinal anesthesia. Intraoperative ephedrine use was similar for both groups. Intraoperative crystalloid administration was statistically greater for patients receiving spinal versus epidural anesthesia (1780 +/- 838 vs. 1359 +/- 674 ml, respectively). Neonatal Apgar scores and incidence of maternal intensive care unit admission or postoperative pulmonary edema were also similar. CONCLUSION: Although we cannot exclude the possibility that the spinal and epidural anesthesia groups were dissimilar, the magnitudes of maternal blood pressure declines were similar after spinal or epidural anesthesia in this series of severely preeclamptic patients receiving cesarean section. Maternal and fetal outcomes also were similar. (+info)
Clinical effects and maternal and fetal plasma concentrations of 0.5% epidural levobupivacaine versus bupivacaine for cesarean delivery.
BACKGROUND: Bupivacaine exists as a mixture of two enantiomers, levobupivacaine and dexbupivacaine. Data suggest that levobupivacaine has equal local anesthetic potency, with reduced potential for central nervous system and cardiovascular toxicity. The present study compares the efficacy of 0.5% levobupivacaine with 0.5% bupivacaine for epidural anesthesia in parturients undergoing elective cesarean delivery. METHODS: Sixty healthy obstetric patients undergoing elective cesarean delivery with epidural anesthesia completed the study. Patients were randomized to receive 30 ml of either 0.5% levobupivacaine or 0.5% bupivacaine in a double-blind fashion. The efficacy endpoint measures included onset, offset, and quality of anesthesia. Neonatal blood gas analyses, Apgar score determinations, and neurobehavioral examinations were performed. Venous samples for pharmacokinetic studies and serial electrocardiograms were obtained in 10 patients in each group. RESULTS: Levels of sensory block, motor block, muscle relaxation, and overall quality of anesthesia did not differ between groups. The frequency of hypotension was 84.4% in the levobupivacaine group and 100% for the bupivacaine group (P < or = 0.053). No significant difference in observed maximum concentration of drug after dosing or area under the plasma drug concentration versus time curve were seen. The maximum concentrations were 1.017 and 1.053 microg/ml, and the areas were 4.082 and 3.765 h(microg/ml) for the levobupivacaine and bupivacaine groups, respectively. Umbilical vein-to-maternal vein ratios were 0.303 for the levobupivacaine group and 0.254 for the bupivacaine group. CONCLUSIONS: The use of epidural 0.5% levobupivacaine for cesarean delivery results in equally efficacious anesthesia compared with 0.5% bupivacaine. Pharmacokinetic parameters were similar in the two groups. (+info)
Glycopyrrolate reduces nausea during spinal anaesthesia for caesarean section without affecting neonatal outcome.
We have tested the hypotheses that glycopyrrolate, administered immediately before induction of subarachnoid anaesthesia for elective Caesarean section, reduces the incidence and severity of nausea, with no adverse effects on neonatal Apgar scores, in a double-blind, randomized, controlled study. Fifty women received either glycopyrrolate 200 micrograms or saline (placebo) i.v. during fluid preload, before induction of spinal anaesthesia with 2.5 ml of 0.5% isobaric bupivacaine. Patients were questioned directly regarding nausea at 3-min intervals throughout operation and asked to report symptoms as they arose. The severity of nausea was assessed using a verbal scoring system and was treated with increments of i.v. ephedrine and fluids. Patients in the group pretreated with glycopyrrolate reported a reduction in the frequency (P = 0.02) and severity (P = 0.03) of nausea. Glycopyrrolate also reduced the severity of hypotension, as evidenced by reduced ephedrine requirements (P = 0.02). There were no differences in neonatal Apgar scores between groups. (+info)
Gastric pressure during emergency caesarean section under general anaesthesia.
Gastric pressure and volume were measured in 20 pregnant women during emergency Caesarean section under general anaesthesia with neuromuscular block. Mean gastric pressure was 11 (range 4-19) mm Hg and we can predict that 99% of women undergoing emergency Caesarean section with neuromuscular block are likely to have gastric pressures of less than 25 mm Hg (mean + 3 SD). This has implications for the amount of cricoid pressure required during induction of anaesthesia. Gastric pressure increased during delivery to 19 mm Hg and fundal pressure caused a gastric pressure of 65 mm Hg in one woman. Gastric pressure decreased significantly after delivery (P < 0.001) to 8 mm Hg. Although we measured large gastric volumes (mean 112 (range 20-350) ml), there was no correlation between gastric volume and gastric pressure. (+info)
French survey of anesthesia in 1996.
BACKGROUND: To identify the growth in the number of anesthetic procedures since 1980 and the changes in the practice of anesthesia, the present survey was designed to collect and analyze the anesthetic activity performed in France in 1996, from a representative sample collected in all French hospitals and clinics. METHODS: This study, initiated by the French Society of Anesthesia and Intensive Care, collected information that included the characteristics of patients (age, sex, American Society of Anesthesiologists status), the techniques of anesthesia, and the nature of the procedure for which anesthesia was required. All French private, public, and military hospitals were asked to participate in the survey. In each hospital in the country, all anesthetic procedures were documented and collected during 3 consecutive days, chosen at random during a 12-month period, to obtain a representative sample of the annual activity. All data were analyzed at the INSERM (National Institute of Health and MEDICAL RESEARCH: At the conclusion of the study, 5% of hospitals were randomly assigned to be audited to check for missing data and errors. The rate of anesthetic activity was calculated as the ratio between the annual number of anesthetic procedures and the number of the general population in the same age group. RESULTS: The participation rate of hospitals was 98%. The analysis of the 62,415 collected questionnaires allowed extrapolation of the anesthetic activity to 7,937,000 anesthetic procedures (95% confidence interval, +/- 387,000) performed in France in 1996. Thus, the annual rate of anesthetic procedures was 13.5 per 100 population, varying between 5.4 per 100 in girls aged 5-14 yr and 30.2 per 100 in men aged 75-84 yr. Surgery was involved in 71% of anesthesia cases. Regional anesthesia alone was performed in 20% of all surgical cases and was combined with general anesthesia in 3% of additional cases. Anesthesia for obstetric procedures represented 9% of all cases. Seventy-six percent of all anesthetic procedures started between 12:00 A.M. and 7:00 A.M. were related to obstetric activities. CONCLUSION: In comparison with a previous study, the present survey shows that the number of anesthetic procedures has increased by 120% since 1980, and the rate of anesthetic procedures increased from 6.6 to 13.5 per 100 population, the major changes being observed in patients aged > or = 75 yr and in those with an American Society of Anesthesiologists physical status of 3. In the same time period, the number of regional anesthetic procedures increased 14-fold. In obstetrics, the practice of epidural analgesia extended from 1.5% to 51% of all deliveries of the country. (+info)