Obstetric Anaesthesia Workload and Time of Day

International Journal of Obstetric Anesthesia. Apr, 2004  |  Pubmed ID: 15321423

The Demise of General Anesthesia in Obstetrics Revisited: Prescription for a Cure

International Journal of Obstetric Anesthesia. Jan, 2005  |  Pubmed ID: 15627530

Single-dose, Sustained-release Epidural Morphine in the Management of Postoperative Pain After Elective Cesarean Delivery: Results of a Multicenter Randomized Controlled Study

Anesthesia and Analgesia. Apr, 2005  |  Pubmed ID: 15781537

In this multicenter, randomized, controlled study, we compared the analgesic efficacy and safety profile of a new single-dose extended-release epidural morphine (EREM) formulation (DepoDur) with that of epidural morphine sulfate for the management of postoperative pain for up to 48 h after elective cesarean delivery. ASA physical status I or II parturients (n = 75) were anesthetized with a combined spinal/epidural technique. Parturients received intrathecal bupivacaine 12-15 mg and fentanyl 10 mug for spinal anesthesia and a single epidural injection of either 5 mg of standard (conventional preservative-free) morphine or 5, 10, or 15 mg of extended-release morphine after cord clamping for postoperative pain control. Single-dose EREM 10 and 15 mg groups significantly decreased total supplemental opioid medication use and improved functional ability scores for 48 h after surgery compared with those receiving 5 mg of standard morphine. Visual analog scale pain scores at rest and with activity at 24 to 48 h after dosing were significantly better in the 10- and 15-mg single-dose EREM groups versus the standard morphine group. There were no significant differences between the two 5 mg (single-dose EREM and standard morphine) groups. Single-dose EREM was well tolerated, and most adverse events were mild to moderate in severity. Single-dose EREM is a potentially beneficial epidural analgesic for the management of post-cesarean delivery pain and has particular advantages over standard morphine for the period from 24 to 48 h after surgery.

Nitroglycerin to Facilitate Insertion of a Labor Epidural

Anesthesiology. Apr, 2005  |  Pubmed ID: 15791131

The ED50 and ED95 of Intrathecal Isobaric Bupivacaine with Opioids for Cesarean Delivery

Anesthesiology. Sep, 2005  |  Pubmed ID: 16129987

The ideal intrathecal isobaric bupivacaine dose for cesarean delivery anesthesia is uncertain. While small doses (5-9 mg) of bupivacaine may reduce side effects such as hypotension, they potentially increase spinal anesthetic failures. This study determined the ED50 and ED95 of intrathecal isobaric bupivacaine (with adjuvant opioids) for cesarean delivery.

Patient Preferences for Anesthesia Outcomes Associated with Cesarean Delivery

Anesthesia and Analgesia. Oct, 2005  |  Pubmed ID: 16192541

When deciding on neuraxial medication (e.g., spinal opioids) for cesarean delivery (CS) under regional anesthesia, anesthesiologists make treatment decisions that "trade off" relieving pain with the potential for increased risk of side effects. No previous studies have examined obstetric patients' anesthesia preferences. Researchers administered 100 written surveys to pregnant women attending our institutions' expectant parent class. We determined patients' preferences for importance of specific intraoperative and postoperative anesthesia outcomes using priority ranking and relative value scales. We also explored patients' fears, concerns, and tolerance regarding CS and analgesics. Eighty-two of 100 surveys were returned and analyzed. Pain during and after CS was the greatest concern followed by vomiting, nausea, cramping, pruritus, and shivering. Ranking and relative value scores were closely correlated (R2 = 0.7). Patients would tolerate a visual analog pain score (0-100 mm) of 56 +/- 22 before exposing their baby to the potential effects of analgesics they receive. In contrast to previous general surgical population surveys that found nausea and vomiting as primary concerns, we found pain during and after CS as parturients' most important concern. Common side effects such as pruritus and shivering caused only moderate concern. This information should be used to guide anesthetic choices, e.g., inclusion of spinal opioids given in adequate doses. IMPLICATIONS: Medical care can be improved by incorporating patients' preferences into medical decision making. We surveyed obstetric patients to determine their preferences regarding potential cesarean delivery anesthesia outcomes. Unlike general surgical patients who rate nausea and vomiting highest, parturients considered pain during and after cesarean delivery the most important concern.

Remifentanil Patient-controlled Analgesia in Labor

Anesthesia and Analgesia. Jan, 2006  |  Pubmed ID: 16368862

Epidural Anesthesia for Elective Cesarean Delivery with Intraoperative Arterial Occlusion Balloon Catheter Placement

Anesthesia and Analgesia. Feb, 2006  |  Pubmed ID: 16428566

Obstetric hemorrhage is a leading cause of maternal mortality. We describe the anesthetic management of elective cesarean delivery in patients at high risk for hemorrhage. The utility and limitations of intraarterial balloon catheter placement and epidural anesthesia are described.

Valdecoxib for Postoperative Pain Management After Cesarean Delivery: a Randomized, Double-blind, Placebo-controlled Study

Anesthesia and Analgesia. Sep, 2006  |  Pubmed ID: 16931678

Although nonsteroidal antiinflammatory drugs (NSAIDs) improve postoperative pain relief after cesarean delivery, they carry potential side effects (e.g., bleeding). Perioperative cyclooxygenase (COX)-2 inhibitors show similar analgesic efficacy to nonsteroidal antiinflammatory drugs in many surgical models but have not been studied after cesarean delivery. We designed this randomized double-blind study to determine the analgesic efficacy and opioid-sparing effects of valdecoxib after cesarean delivery. Healthy patients undergoing elective cesarean delivery under spinal anesthesia were randomized to receive oral valdecoxib 20 mg or placebo every 12 h for 72 h postoperatively. As a result of cyclooxygenase-2 inhibitors safety concerns that became apparent during this study, the study was terminated early after evaluating 48 patients. We found no differences in total analgesic consumption between the valdecoxib and placebo groups (121 +/- 70 versus 143 +/- 77 morphine mg-equivalents, respectively; P = 0.26). Pain at rest and during activity were similar between the groups despite adequate post hoc power to have detected a clinically significant difference. There were also no differences in IV morphine requirements, time to first analgesic request, patient satisfaction, side effects, breast-feeding success, or functional activity. Postoperative pain was generally well controlled. Adding valdecoxib after cesarean delivery under spinal anesthesia with intrathecal morphine is not supported at this time.

Experimental Heat Pain for Detecting Pregnancy-induced Analgesia in Humans

Anesthesia and Analgesia. Nov, 2006  |  Pubmed ID: 17056970

Animal studies suggest that increased circulating estrogen and progesterone, and activation of the endorphin system cause prenancy-induced antinociceptive effects. Human studies have provided inconsistent results and have often lacked a nonpregnant control group. In this study, we compared sensitivity to experimental heat and cold pain in pregnant and nonpregnant women. Nineteen healthy nonpregnant female volunteers and 20 pregnant women at term were enrolled. Pain threshold and tolerance were examined using experimental heat-induced pain and cold pressor pain models. Subjects were evaluated pre- and 1-2 days post-delivery (pregnant), or on consecutive days (nonpregnant). Heat pain tolerance was significantly increased in the pregnant women during pre and postdelivery when compared with nonpregnant controls (50.0 +/- 1.0 vs 49.0 +/- 1.2 and 50.1 +/- 0.7 vs 49.2 +/- 1.2 degrees C; mean +/- sd). However, pain induced by the cold pressor test was endured for a similar amount of time by both study groups. Pregnancy-induced analgesic effects at term can be detected in a model of experimental heat pain. These effects persist during the first 24-48 h after delivery. Experimental heat pain is a suitable modality for further characterizing the phenomenon of pregnancy-induced analgesia in humans.

The Effect of Colloid and Crystalloid Preloading on Thromboelastography Prior to Cesarean Delivery

Canadian Journal of Anaesthesia = Journal Canadien D'anesthésie. Mar, 2007  |  Pubmed ID: 17331930

Fluid preloading with colloids reduces hypotension after spinal anesthesia for Cesarean delivery more effectively than crystalloids. However, the effects of fluid preloading regimens on coagulation in pregnant patients remain unresolved. The aim of this study was to compare the effects on coagulation of fluid preloading with 6% hydroxyethyl starch (HES) and lactated Ringer's (LR) solution using thromboelastography (TEG) with kaolin-activated whole blood in healthy pregnant patients prior to spinal anesthesia for Cesarean delivery.

Neuraxial Anesthesia for Cesarean Delivery in a Parturient with Type 1 Von Willebrand Disease and Scoliosis

Journal of Clinical Anesthesia. May, 2007  |  Pubmed ID: 17531735

We present the case of a parturient with von Willebrand disease and scoliosis who required cesarean delivery. Neuraxial anesthesia was used for the patient. The indications for neuraxial anesthesia with regard to type 1 von Willebrand disease are reviewed.

Single-dose, Extended-release Epidural Morphine (DepoDur) Compared to Conventional Epidural Morphine for Post-cesarean Pain

Anesthesia and Analgesia. Jul, 2007  |  Pubmed ID: 17578973

A single-dose of neuraxial morphine sulfate provides good post-Cesarean analgesia; however, its efficacy is limited to the first postoperative day. In a recent phase III study, extended-release epidural morphine (EREM) formulation provided more effective, prolonged analgesia after Cesarean delivery, compared to conventional epidural morphine. However, the study protocol did not allow for the use of nonsteroidal antiinflammatory drugs, used various postoperative analgesics, and monitoring and treatment of respiratory depression were not standardized. Our aims in this study were to compare postoperative analgesic consumption, pain scores and side effects of EREM with conventional morphine for the management of post-Cesarean pain in a setting more reflective of current obstetric practice.

The Episure Syringe: a Novel Loss of Resistance Syringe for Locating the Epidural Space

Anesthesia and Analgesia. Oct, 2007  |  Pubmed ID: 17898406

The Episure syringe is a unique spring-loaded loss-of-resistance (LOR) syringe with a coaxial compression spring within a Portex Pulsator LOR syringe. This syringe supplies a constant pressure while the operator is advancing the Tuohy needle.

Intraoperative Forced Air-warming During Cesarean Delivery Under Spinal Anesthesia Does Not Prevent Maternal Hypothermia

Anesthesia and Analgesia. Nov, 2007  |  Pubmed ID: 17959975

Prewarming and intraoperative warming with forced air-warming systems prevent perioperative hypothermia and shivering in patients undergoing elective cesarean delivery with epidural anesthesia. We tested the hypothesis that intraoperative lower body forced air-warming prevents hypothermia in patients undergoing elective cesarean delivery with spinal anesthesia.

Fetal Oxygen Saturation After Combined Spinal-epidural Labor Analgesia: a Case Series

Journal of Clinical Anesthesia. Sep, 2007  |  Pubmed ID: 17967682

Fetal oxygen saturation (FSpo(2)) is an emerging technology for intrapartum fetal monitoring. We monitored FSpo(2) before and after combined spinal-epidural analgesia in 8 laboring women requesting neuraxial analgesia. Fetal heart rate (FHR) and FSpo(2) (using the Nellcor N400/FS14 system [Nellcor, Pleasanton, CA]) were recorded at baseline and every minute for 45 minutes after analgesia. We observed no significant changes in FSpo(2) after analgesia (mean DeltaFSpo(2) 2 +/- 7 %, P = 0.46). Fetal oxygen saturation at baseline and after analgesia was 53% +/- 9% and 51% +/- 8%, respectively. We observed no significant FHR changes or any fetal bradycardia following combined spinal-epidural analgesia.

Local and Systemic Release of Cytokines, Nerve Growth Factor, Prostaglandin E2, and Substance P in Incisional Wounds and Serum Following Cesarean Delivery

The Journal of Pain : Official Journal of the American Pain Society. Jul, 2008  |  Pubmed ID: 18394968

The objectives of this study were to test the feasibility of measuring inflammatory and nociceptive biochemical mediators at the surgical site and to evaluate the relationship between wound and serum levels as well as determine any associations between mediator release, pain, and analgesic consumption after cesarean delivery. Twenty healthy women undergoing elective cesarean delivery with spinal anesthesia were enrolled. Wound exudate and serum mediators, pain scores, and analgesic consumption were measured at 1, 6, 24, and 48 hours after cesarean. In wound exudate, 19 of 20 mediators were reliably detected including interleukin (IL)-1beta, IL-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IL-17, tumor necrosis factor-alpha, interferon-gamma, granulocyte colony stimulating factor (G-CSF), granulocyte-macrophage colony stimulating factor (GM-CSF), monocyte chemoattractant protein 1 (MCP-1) and macrophage inflammatory protein 1 (MIP-1beta), nerve growth factor (NGF), prostaglandin E2 (PG-E2), and substance P. Wound PG-E2 and various cytokines peaked early, whereas NGF showed a more delayed release. There were no correlations between the concentration versus time profile of wound and serum cytokines. Analgesic consumption during the first 24 hours after surgery was negatively correlated with IL-1beta, IL-6, and G-CSF in the wound exudate. This study demonstrates the feasibility of collecting and measuring nociceptive and inflammatory mediators in surgical wounds at specific time points. The lack of significant correlations between wound and serum levels emphasizes the importance of determining site-specific release if localized pathologies are to be studied. PERSPECTIVE: This study demonstrates the feasibility of measuring real-time nociceptive and inflammatory mediators in surgical wounds. Our findings confirm the lack of correlation between wound and serum levels of many pro-inflammatory and anti-inflammatory cytokines and nerve growth factor.

Labor and Cesarean Delivery Patterns

Anesthesiology. Jul, 2008  |  Pubmed ID: 18580198

Respiratory Depression After Neuraxial Opioids in the Obstetric Setting

Anesthesia and Analgesia. Sep, 2008  |  Pubmed ID: 18713913

Neuraxial opioids have contributed significantly to improved labor and postcesarean delivery analgesia. In the obstetric population, epidural and intrathecal opioids are associated with a very low risk of clinically significant respiratory depression. Although rare, respiratory depression is a serious risk; patients may die or suffer permanent brain damage as a consequence. This review discusses the mechanism and incidence, as well as the prevention, detection, and management of respiratory depression with morphine, extended-release epidural morphine, and lipophilic opioids in the labor and cesarean delivery setting.

Epidural Labor Analgesia in a Patient Receiving Fondaparinux

International Journal of Obstetric Anesthesia. Jan, 2009  |  Pubmed ID: 19046870

A Randomized Trial of Maximum Cephalad Sensory Blockade with Single-shot Spinal Compared with Combined Spinal-epidural Techniques for Cesarean Delivery

Anesthesia and Analgesia. Jan, 2009  |  Pubmed ID: 19095857

Previous studies have shown more extensive cephalad sensory blockade in women receiving combined spinal-epidural (CSE) anesthesia compared with single-shot spinal (SSS) anesthesia for elective cesarean delivery. It has been postulated that introduction of the epidural needle during CSE disturbs the negative pressure in the epidural space, resulting in relatively greater cerebrospinal fluid (CSF) pressure and increased spread of intrathecal local anesthetic. We tested the hypothesis that CSE results in more extensive cephalad sensory blockade than SSS anesthesia and that loss-of-resistance during initiation of CSE anesthesia increases CSF pressure compared with SSS.

Patient-controlled Epidural Analgesia for Labor

Anesthesia and Analgesia. Mar, 2009  |  Pubmed ID: 19224805

Patient-controlled epidural analgesia (PCEA) for labor was introduced into clinical practice 20 yr ago. The PCEA technique has been shown to have significant benefits when compared with continuous epidural infusion. We conducted a systematic review using MEDLINE and EMBASE (1988-April 1, 2008) of all randomized, controlled trials in parturients who received PCEA in labor in which one of the following comparisons were made: background infusion versus none; ropivacaine versus bupivacaine; high versus low concentrations of local anesthetics; and new strategies versus standard strategies. The outcomes of interest were maternal analgesia, satisfaction, motor block, and the incidence of unscheduled clinician interventions. A continuous background infusion improved maternal analgesia and reduced unscheduled clinician interventions. Larger bolus doses (more than 5 mL) may provide better analgesia compared with small boluses. Low concentrations of bupivacaine or ropivacaine provide excellent analgesia without significant motor block. Many strategies with PCEA can provide effective labor analgesia. High volume, dilute local anesthetic solutions with a continuous background infusion appear to be the most successful strategy. Research into new delivery strategies, such as mandatory programmed intermittent boluses and computerized feedback dosing, is ongoing.

Elevation of Uterine Basal Tone and Fetal Heart Rate Abnormalities After Labor Analgesia: a Randomized Controlled Trial

Obstetrics and Gynecology. Jun, 2009  |  Pubmed ID: 19461449

A Survey of Perioperative and Postoperative Anesthetic Practices for Cesarean Delivery

Anesthesiology Research and Practice. 2009  |  Pubmed ID: 21217809

The aim of this survey was to review cesarean delivery anesthetic practices. An online survey was sent to members of the Society of Obstetric Anesthesia and Perinatology (SOAP). The mode of anesthesia, preferred neuraxial local anesthetic and opioid agents, postoperative analgesic regimens, and monitoring modalities were assessed. 384 responses from 1,081 online survey requests were received (response rate = 36%). Spinal anesthesia is most commonly used for elective cesarean delivery (85% respondents), with 90% of these respondents preferring hyperbaric bupivacaine 0.75%. 79% used intrathecal fentanyl and 77% used morphine (median [range] dose 200 mcg [50-400]). 91% use respiratory rate, 61% use sedation scores, and 30% use pulse oximetry to monitor for postoperative respiratory depression after administration of neuraxial opioids. Postoperative analgesic regimens include: nonsteroidal anti-inflammatory agents, acetaminophen, oxycodone, and hydrocodone by 81%, 45%, 25%, and 27% respondents respectively. The majority of respondents use spinal anesthesia and neuraxial opioids for cesarean delivery anesthesia. There is marked variability in practices for monitoring respiratory depression postdelivery and for providing postoperative analgesia. These results may not be indicative of overall practice in the United States due to the select group of anesthesiologists surveyed and the low response rate.

Cost-effectiveness of External Cephalic Version for Term Breech Presentation

BMC Pregnancy and Childbirth. 2010  |  Pubmed ID: 20092630

External cephalic version (ECV) is recommended by the American College of Obstetricians and Gynecologists to convert a breech fetus to vertex position and reduce the need for cesarean delivery. The goal of this study was to determine the incremental cost-effectiveness ratio, from society's perspective, of ECV compared to scheduled cesarean for term breech presentation.

Deficits in the Provision of Cardiopulmonary Resuscitation During Simulated Obstetric Crises

American Journal of Obstetrics and Gynecology. Aug, 2010  |  Pubmed ID: 20417476

Previous work suggests the potential for suboptimal cardiopulmonary resuscitation (CPR) in the parturient but did not directly assess actual performance.

Survey of the Factors Associated with a Woman's Choice to Have an Epidural for Labor Analgesia

Anesthesiology Research and Practice. 2010  |  Pubmed ID: 20721286

Objectives. The purpose of this study was to determine the factors associated with whether a woman received an epidural in labor and to determine the main source used to obtain information about labor epidurals. Methods. Over a one-month period, we surveyed all patients who labored, the day after their delivery. We used multiple logistic regression to identify potential predictive factors after initial univariate analysis. Results. 320 women who met enrollment criteria delivered during the study period and 94% completed the study. Of the 302 patients surveyed, 80% received an epidural for labor. Univariate analysis showed the following variables were associated with whether women received an epidural (P < .01): partner preference, prior epidural, language, education, type of insurance, age, duration, and pitocin use. Using computed multiple logistic regression only partner preference and prior epidural were associated with whether women received an epidural. Conclusion. It was not surprising that a previous epidural was predictive of a patient receiving an epidural. The strong association with partner preference and epidural use suggests this is an important factor when counseling pregnant women with regard to their decision to have a labor epidural.

Continuous Subcutaneous Instillation of Bupivacaine Compared to Saline Reduces Interleukin 10 and Increases Substance P in Surgical Wounds After Cesarean Delivery

Anesthesia and Analgesia. Dec, 2010  |  Pubmed ID: 20861424

Recent evidence suggests that locally delivered local anesthetics may exert tissue-damaging effects such as chondrolysis after intraarticular injection. Alteration of the inflammatory response is a potential mechanism for local anesthetic-induced tissue toxicity. In this study, we tested the effects of continuous local anesthetic infiltration on the release of inflammatory and nociceptive mediators in skin wounds after cesarean delivery.

The Role of Interleukin-1 in Wound Biology. Part I: Murine in Silico and in Vitro Experimental Analysis

Anesthesia and Analgesia. Dec, 2010  |  Pubmed ID: 20889942

Wound healing is a multistep, complex process that involves the coordinated action of multiple cell types. Conflicting results have been obtained when conventional methods have been used to study wound biology. Therefore, we analyzed the wound response in a mouse genetic model.

The Role of Interleukin-1 in Wound Biology. Part II: In Vivo and Human Translational Studies

Anesthesia and Analgesia. Dec, 2010  |  Pubmed ID: 20889944

In the accompanying paper, we demonstrate that genetic variation within Nalp1 could contribute to interstrain differences in wound chemokine production through altering the amount of interleukin (IL)-1 produced. We further investigate the role of IL-1 in incisional wound biology and its effect on wound chemokine production in vivo and whether this mechanism could be active in human subjects.

Effect of a Preemptive Femoral Nerve Block on Cytokine Release and Hyperalgesia in Experimentally Inflamed Skin of Human Volunteers

Regional Anesthesia and Pain Medicine. Nov-Dec, 2010  |  Pubmed ID: 20975465

Tissue injury is associated with the local release of inflammatory and nociceptive mediators and the development of hyperalgesia. It is unclear whether interrupting neuronal signaling using regional anesthetic techniques at the time of the injury modifies local nociceptive and inflammatory processes. The aim of this study was to determine whether a peripheral nerve block at the time of tissue injury could modify the development of wound hyperalgesia and the local release of inflammatory and nociceptive mediators.

Retrospective Analysis of Anesthetic Interventions for Obese Patients Undergoing Elective Cesarean Delivery

Journal of Clinical Anesthesia. Nov, 2010  |  Pubmed ID: 21056808

To examine the relationship between body mass index (BMI), perioperative times, and anesthetic interventions in patients undergoing elective cesarean delivery.

ED(50) and ED(95) of Intrathecal Bupivacaine in Morbidly Obese Patients Undergoing Cesarean Delivery

Anesthesiology. Mar, 2011  |  Pubmed ID: 21307769

It has been suggested that morbidly obese parturients may require less local anesthetic for spinal anesthesia. The aim of this study was to determine the effective dose (ED(50)/ED(95)) of intrathecal bupivacaine for cesarean delivery in morbidly obese patients.

A Sensitive Assay for the Quantification of Morphine and Its Active Metabolites in Human Plasma and Dried Blood Spots Using High-performance Liquid Chromatography-tandem Mass Spectrometry

Analytical and Bioanalytical Chemistry. May, 2011  |  Pubmed ID: 21400080

Opioids such as morphine are the cornerstone of pain treatment. The challenge of measuring the concentrations of morphine and its active metabolites in order to assess human pharmacokinetics and monitor therapeutic drugs in children requires assays with high sensitivity in small blood volumes. We developed and validated a semi-automated LC-MS/MS assay for the simultaneous quantification of morphine and its active metabolites morphine 3β-glucuronide (M3G) and morphine 6β-glucuronide (M6G) in human plasma and in dried blood spots (DBS). Reconstitution in water (DBS only) and addition of a protein precipitation solution containing the internal standards were the only manual steps. Morphine and its metabolites were separated on a Kinetex 2.6-μm PFP analytical column using an acetonitrile/0.1% formic acid gradient. The analytes were detected in the positive multiple reaction mode. In plasma, the assay had the following performance characteristics: range of reliable response of 0.25-1000 ng/mL (r(2) > 0.99) for morphine, 1-1,000 ng/mL (r(2) > 0.99) for M3G, and 2.5-1,000 ng/mL for M6G. In DBS, the assay had a range of reliable response of 1-1,000 ng/mL (r(2) > 0.99) for morphine and M3G, and of 2.5-1,000 ng/mL for M6G. For inter-day accuracy and precision for morphine, M3G and M6G were within 15% of the nominal values in both plasma and DBS. There was no carryover, ion suppression, or matrix interferences. The assay fulfilled all predefined acceptance criteria, and its sensitivity using DBS samples was adequate for the measurement of pediatric pharmacokinetic samples using a small blood of only 20-50 μL.

Oxytocin for Labour and Caesarean Delivery: Implications for the Anaesthesiologist

Current Opinion in Anaesthesiology. Jun, 2011  |  Pubmed ID: 21415725

The implications of the obstetric use of oxytocin for obstetric anaesthesia practice are summarised. The review focuses on recent research on the uterotonic effects of oxytocin for prophylaxis and management of uterine atony during caesarean delivery.

Crossing the Pond: Applying to Train in the USA

British Journal of Hospital Medicine (London, England : 2005). Apr, 2011  |  Pubmed ID: 21537230

Prior Epidural Lidocaine Alters the Pharmacokinetics and Drug Effects of Extended-release Epidural Morphine (DepoDur®) After Cesarean Delivery

Anesthesia and Analgesia. Aug, 2011  |  Pubmed ID: 21642610

A potential physicochemical interaction between epidural local anesthetics and extended-release epidural morphine (EREM) could negate the sustained release. In this study, we sought to determine the pharmacokinetic and drug effects of prior epidural lidocaine administration on EREM.

Challenges in Interpreting Joined Allelic Combinations of OPRM1 and COMT Genes

Anesthesia and Analgesia. Aug, 2011  |  Pubmed ID: 21788333

Neuraxial Morphine and Respiratory Depression: Finding the Right Balance

Drugs. Oct, 2011  |  Pubmed ID: 21942973

Morphine is a drug commonly administered via the epidural or intrathecal route, and is regarded by many as the 'gold-standard' single-dose neuraxial opioid due to its postoperative analgesic efficacy and prolonged duration of action. However, respiratory depression is a recognized side effect of neuraxial morphine administered in the perioperative setting. We conducted an extensive review of articles published since 1945 that examine respiratory depression or failure associated with perioperative intrathecal or epidural morphine use. Respiratory depression was previously thought to result from the interaction of opioid in the cerebrospinal fluid with ventral medullary opioid receptors. More recently, the preBötzinger complex located in the medulla has been identified as the site responsible for the decrease in respiratory rate following systemic administration of opioids. Neurons in the preBötzinger complex expressing neurokinin-1 receptors are selectively inhibited by opioids, and therefore are the mediators of opioid-induced respiratory depression. Epidural, intrathecal and plasma pharmacokinetics of opioids are complex, vary between neuraxial compartments, and can even differ within the epidural space itself depending upon level of insertion. Caution should be exercised when prescribing systemic opioids (intravenous or oral) in addition to neuraxial morphine as this can compound the potential for early or delayed respiratory depression. There is a wide range of incidences for respiratory depression following neuraxial morphine in a perioperative setting. Disparity of definitions used for the diagnosis of respiratory depression in the literature precludes identification of the exact incidence of this rare event. The optimal neuraxial opioid dose is a balance between the conflicting demands of providing optimal analgesia while minimizing dose-related adverse effects. Dose-response studies show that neuraxial morphine appears to have an analgesic efficacy 'ceiling'. The optimal 'single-shot' intrathecal dose appears to be 0.075-0.15 mg and the ideal 'single-shot' epidural morphine dose is 2.5-3.75 mg. Analgesic efficacy studies have not been adequately powered to show differences in the incidence of clinically significant respiratory depression. Opioid antagonists such as naloxone to prevent or treat opioid-induced respiratory depression have a number of limitations. Researchers have recently focused on non-opioid drugs such as serotonin receptor agonists. Early evidence suggests that ampakine (α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid [AMPA]) receptor modulators may be effective at reducing opioid-induced respiratory depression while maintaining analgesia. Sodium/proton exchanger type 3 (NHE3) inhibitors, which act centrally on respiratory pathways, also warrant further study.

Labor Room Setting Compared with the Operating Room for Simulated Perimortem Cesarean Delivery: a Randomized Controlled Trial

Obstetrics and Gynecology. Nov, 2011  |  Pubmed ID: 22015877

To compare the labor room and operating room for perimortem cesarean delivery during simulated maternal arrests occurring outside the operating room. We hypothesized transport to the operating room for perimortem cesarean delivery would delay incision and other important resuscitation milestones.

Epidural Catheter Removal in Patients on Warfarin Thromboprophylaxis: a More Cautious Interpretation of Results Required?

Regional Anesthesia and Pain Medicine. Nov-Dec, 2011  |  Pubmed ID: 22024706

Endotracheal Tube Cuff Pressure Monitoring: a Review of the Evidence

Journal of Perioperative Practice. Nov, 2011  |  Pubmed ID: 22165491

Tracheal intubation constitutes a routine part of anaesthetic practice both in the operating theatre as well as in the care of critically ill patients. The procedure is estimated to be performed 13-20 million times annually in the United States alone. There has been a recent renewal of interest in the morbidity associated with endotracheal tube cuff overinflation, particularly regarding the rationale and requirement for endotracheal tube cuff monitoring intra-operatively.

Continuous Spinal Anesthesia for Cesarean Hysterectomy and Massive Hemorrhage in a Parturient with Placenta Increta

Canadian Journal of Anaesthesia = Journal Canadien D'anesthésie. May, 2012  |  Pubmed ID: 22395824

We present anesthetic management using a continuous spinal anesthesia (CSA) technique in a patient with placenta increta who underwent elective Cesarean hysterectomy with massive postpartum hemorrhage.

Ultrasound-guided Popliteal Nerve Block in a Patient with Malignant Degeneration of Neurofibromatosis 1

Case Reports in Anesthesiology. 2012  |  Pubmed ID: 22649742

A 41-year-old female patient with neurofibromatosis 1 presented with new neurologic deficits secondary to malignant degeneration of a tibial lesion. Ultrasound mapping of the popliteal nerve revealed changes consistent with an intraneural neurofibroma. Successful popliteal nerve blockade was achieved under ultrasound guidance.