Summary

Background and objective: For many, the administration of additional oxygen to the women receiving regional anaesthesia for Caesarean section is traditional, but for others it is controversial because of doubts about its efficacy. The aim of our study was to determine if beneficial effects of maternal oxygen therapy on the fetus could be revealed using a neonatal behavioural scoring system. Methods: Sixty women with a normal singleton pregnancy beyond 36 weeks gestation, undergoing elective Caesarean section under spinal anaesthesia were randomized into two groups: Group 1 received air and oxygen mixture through a Hudson style face mask (FiO2 of 0.21–0.25). Group 2 received FiO2 of 0.40–0.60 through an identical Hudson style face mask. Neurologic Adaptive Capacity Score on all the infants within 5 min of birth and between 10 and 24 h after the Caesarean delivery was performed. Apgar score, umbilical venous blood oxygen tension and umbilical artery standardized base excess were recorded. Results: Initial Neurologic Adaptive Capacity Scores at birth in Groups 1 and 2 were 32.6 (SD 4.6) and 31.3 (SD 4.3), respectively. Latter scores were 36.0 (SD 3.0) and 36.5 (SD 1.9), respectively. Neither were statistically significant. There were no significant differences between the groups for any of the recorded variables. Conclusions: Administering maternal oxygen using a standard commercial Hudson style face mask does not appear to significantly improve oxygen delivery to, nor does it influence acidosis or behavioural effects in, the normal neonate at elective Caesarean delivery with spinal anaesthesia.

Summary

Background and objective: There is a controversy regarding the best drug for prevention of nausea and vomiting in patients receiving intrathecal morphine. The aim of this study was to examine efficacy and tolerability of droperidol compared with ondansetron for the prevention of morphine-induced nausea and vomiting. Methods: In a randomized, placebo-controlled trial, 120 women undergoing Caesarean section under spinal anaesthesia with intrathecal morphine 0.1 mg received intravenous ondansetron 4 mg (n = 40), droperidol 1.25 mg (n = 40) or saline (n = 40) immediately after umbilical-cord clamping. Nausea and vomiting were graded according to intensity at 1, 2, 4, 6, 12 and 24 h. Results: Nausea or vomiting occurred in 14 patients (35%) in the placebo group, 4 (10%) in the ondansetron group and 10 (25%) in the droperidol group; the difference between ondansetron and placebo was statistically significant (P = 0.007). Eleven of the 14 placebo patients (27.5%) vomited, compared with none of the 4 ondansetron patients (vs. placebo, P = 0.0004) and 5 of the droperidol patients (vs. placebo, P = 0.18). Three of the 14 placebo patients (7.5%) were nauseous, compared with 4 (10%) receiving ondansetron and 5 (12.5%) receiving droperidol. Conclusions: Ondansetron was effective in reducing the incidence of nausea and vomiting in patients receiving intrathecal morphine for Caesarean section.

Summary

Background and objective: Motor function recovers rapidly but the extended duration of sensory block after spinal anaesthesia with hyperbaric ropivacaine may delay patients' ambulation after surgery. We tested whether compensating a reduction of the ropivacaine dose with a small dose of lidocaine would be adequate for surgery and shorten recovery from spinal anaesthesia. Methods: Fifty-six consecutive outpatients, who were scheduled for lower extremity surgery under spinal anaesthesia, were randomized into two groups to receive either a hyperbaric solution of lidocaine 20 mg and ropivacaine 5 mg (Group LR) or hyperbaric ropivacaine 10 mg (Group R). Sensory block was tested with pinprick and motor block on the Bromage scale at 5-min intervals until 30 min, then at 15-min intervals until 90 min, and thereafter at 30-min intervals until full bilateral recovery. Blinded interviews were performed on the first and seventh postoperative day. Results: The groups did not differ significantly regarding success of sensory block reaching T10 dermatome on the operative side, 24 (86%) in Group LR and 23 (82%) in Group R, median (range) onset time 5 (5–20) vs. 10 (5–25) min or median duration of T10 sensory block 68 (5–115) vs. 50 (20–115) min, respectively. Two patients in each group required general anaesthesia. Recovery did not differ between the groups, median time of full motor recovery was 75 min in both groups, sensory recovery of S2 2.5 h vs. 2.8 h, first voluntary micturition 4.2 (2.2–6.1) vs. 4.5 (2.4–6.6) h in the LR vs. R Group, respectively. Transient neurological symptoms did not appear. Conclusion: It is concluded that spinal anaesthesia with hyperbaric lidocaine 20 mg + ropivacaine 5 mg and hyperbaric ropivacaine 10 mg was quite similar regarding frequency, onset, duration of T10 dermatome sensory block and recovery. The patients would have been ready for discharge after voluntary micturition, 4.2–4.5 h from the subarachnoid injection of local anaesthetics.

Summary

Background and objective: The aim of this study was to evaluate prostate anaesthetic block for haemodynamic tolerance and quality of analgesia during and after transurethral surgery. Methods: Ninety adult males, ASA III/IV, were randomly assigned to receive a prostate anaesthetic block (n = 45) or spinal anaesthesia (n = 45). The main outcome measurement during anaesthesia, surgery and recovery was haemodynamic tolerance (number of hypotensive episodes, heart rate, systolic and mean blood pressures). Other outcome variables were pain scores during anaesthesia, surgery and every 4 h until 24 h after the end of surgery and amount of oral morphine required during the 24-h postoperative period. Results: Sixty-six patients were ASA III and 24 ASA IV. Ongoing cardiovascular therapies were comparable between groups. All surgical procedures were performed under good conditions. For patients receiving prostate anaesthetic block, the blood pressure and heart rate did not change significantly during the study period. For patients receiving spinal anaesthesia, the hypotension rate was 55.6% (n = 25) compared to 0 in the prostate anaesthetic block group (P < 0.001); 25 and 4 patients, respectively, required vascular filling and additional ephedrine administration. In both groups, all pain scores were <40 (100 mm visual analogue scale) during the study period. Oral morphine was given during the postoperative period to two prostate anaesthetic block patients and four who had received spinal anaesthesia (not significant). Conclusion: Transurethral surgery under prostate anaesthetic block is safe and assures adequate analgesia during and after surgery.

Summary

Background and objectives: To compare the analgesic effects of intrathecal fentanyl and low-dose intravenous ketamine as adjuvants to intrathecal bupivacaine for Caesarean section. Methods: Ninety elective Caesarean section patients were randomized into three groups. Spinal anaesthesia was performed with 15 mg hyperbaric bupivacaine in all groups. Ketamine (0.15 mg kg−1) or an equal volume of normal saline was given intravenously immediately after initiating spinal anaesthesia in the ketamine and control group, respectively. In the fentanyl group, 10 μg fentanyl was added to the intrathecal bupivacaine. Arterial pressures, heart rate values, adverse effects, the time of first request for postoperative analgesia, visual analogue pain scores, total analgesic consumptions at 24 and 48 h were recorded in all patients. Results: The time to first request for analgesia was significantly longer in the ketamine (197 min) and fentanyl (165 min) groups compared to the control group (144 min). Postoperative pain scores were significantly lower in the ketamine group than in both other groups. Although the analgesic requirements during first 24 h were significantly lower in the ketamine group, there was no significant difference between the groups during the following 24 h. Conclusion: Intravenous low-dose ketamine combined with intrathecal bupivacaine for Caesarean section provides longer postoperative analgesia and lower postoperative analgesic consumption than bupivacaine alone suggesting a pre-emptive effect.

Summary

Background and objective: The aim of the study was to report our experience concerning the effectiveness, complications and safety of spinal anaesthesia, and to determine whether spinal anaesthesia was effective in full-term infants undergoing elective inguinal hernia repair.

Methods: Sixty-eight full-term infants aged <6 months were included in the study. Infants were divided into three groups; Group I (<1 month, n = 20), Group II (>1 and <3 months, n = 26), and Group III (3–6 months, n = 22). All spinal blocks were performed under mask inhalation anaesthesia. A dose of bupivacaine 0.5% 0.5 mg kg−1 was used for infants under 5 kg and 0.4 mg kg−1 for those over 5 kg. Heart rate, mean arterial pressure, respiratory rate and SPO2 were recorded before and after spinal anaesthesia at 5 min intervals. Time to onset of analgesia, time to start of operation, duration of operation, anaesthesia and hospitalization, postoperative analgesic requirement and complications were recorded.

Results: Adequate spinal anaesthesia without sedation was better, time to obtain maximum cutaneous analgesia was shorter and need for sedation and postoperative analgesic requirement were significantly lower in Group I. Although heart rate, mean arterial pressure and respiratory rate decreased <20% in all groups following spinal analgesia, the decrease in Group I was lower than the others.

Conclusions: Spinal anaesthesia is an effective choice in inguinal hernia repair for full-term infants aged <1 month, providing excellent and reliable surgical conditions. However, this technique is not as useful for infants aged between 1 and 6 months.

Summary

Background and objective: Our purpose was to evaluate the analgesic and sedative effects of intrathecal midazolam when added to spinal bupivacaine in patients undergoing perianal surgery under spinal anaesthesia.

Methods: Forty-four patients were randomly allocated into two equal groups: Group I (B) received hyperbaric bupivacaine 0.5% 2 mL + saline 0.9% 1 mL in a total volume of 3 mL intrathecally; Group II (BM) received hyperbaric bupivacaine 0.5% 2 mL + 1 mL of 2 mg preservative-free midazolam in a total volume of 3 mL intrathecally. In both groups, the onset and recovery times of sensory block, the degree and recovery times of motor block as well as the sedation and visual analogue pain scores were recorded, and statistically compared.

Results: In Group BM, the postoperative visual analogue pain scores were significantly lower at the first 4 h (P < 0.05), the average time until the first dose of additional analgesic requirement was significantly longer (P < 0.05), and sedation scales were significantly higher (P < 0.05), compared to Group B. There were no statistically significant differences in the onset and the full recovery times of sensory and motor blocks in the two groups.

Conclusion: The use of intrathecal midazolam combined with intrathecal bupivacaine produces a more effective and longer analgesia with a mild sedative effect in perianal surgery.

Summary

Background and objective: Epidural anaesthesia is the preferred technique of anaesthesia for Caesarean section in pre-eclampsia. Spinal anaesthesia is considered by some as a safe and effective alternative, which is especially useful in emergency situations. Combined spinal–epidural anaesthesia, using low doses of local anaesthetics with opioids, is effective and reduces the incidence of hypotension in normal pregnancy. We performed a retrospective chart analysis to evaluate the effects of combined spinal–epidural anaesthesia on maternal haemodynamics and fetal outcome compared to conventional epidural anaesthesia.

Methods: A retrospective anaesthesia chart analysis of all pre-eclamptic patients who underwent Caesarean section over a 4 yr period was performed. Patient characteristic, obstetric, haemodynamic, fetal and neonatal data were gathered and analysed according to the anaesthetic technique used.

Results: Seventy-seven pre-eclamptic parturients undergoing Caesarean section were identified (26 women were severely pre-eclamptic and 51 demonstrated mild pre-eclampsia). Epidural anaesthesia was performed in 62 patients and combined spinal–epidural anaesthesia was performed in 15. No differences in patient characteristic and obstetric data were noted. Highest mean arterial pressure prior to anaesthesia was comparable between the groups (epidural: 106 ± 12 vs. combined spinal–epidural anaesthesia: 109 ± 18 mmHg) as well as the lowest recorded mean arterial pressure following anaesthesia (epidural: 93 ± 13 vs. combined spinal–epidural anaesthesia: 98 ± 17 mmHg). In the combined spinal–epidural anaesthesia group more ephedrine was used compared to the epidural group (14.6 ± 4.4 vs. 3.6 ± 4.6 mg, P<0.05). However, more lactated Ringer's was used in the epidural group. Umbilical artery pH was lower in the epidural group (7.26 ± 0.01 vs. 7.29 ± 0.02, P<0.05). Similar results were noted in 26 severely pre-eclamptic patients. Seven women underwent combined spinal– epidural anaesthesia and 19 underwent epidural anaesthesia in the severely pre-eclamptic group. Also more ephedrine was used in the combined spinal–epidural anaesthesia group. A tendency towards a lower umbilical artery pH was observed in the epidural group but this difference did not reach statistical significance.

Conclusions: Combined spinal–epidural anaesthesia appears to be safe as anaesthetic technique for pre-eclampsia and severe pre-eclampsia. However, it is important to consider the retrospective design of the study and the large number of epidural anaesthetics performed.

Summary

Background and objective: Intrathecal ketamine as the sole anaesthetic agent has demonstrated a lack of cardiovascular depression that should be of advantage in an elderly population. S(+) ketamine has three-times the analgesic potency of R(−) ketamine and its antinociceptive effects after intrathecal administration in rats are known. We decided to evaluate the effects of intrathecal S(+) ketamine added to a small dose of spinal bupivacaine in elderly patients undergoing transurethral prostate surgery.

Methods: Forty males over 60 yr old, scheduled for transurethral prostate resection under spinal anaesthesia, were studied in a prospective, double-blinded, randomized way. Patients were allocated to receive either bupivacaine 10 mg or bupivacaine 7.5 mg combined with S(+) ketamine 0.1 mg kg−1. Spinal block onset time, maximum sensory level, duration of blockade, haemodynamic variables, postoperative analgesic requirements and adverse events were recorded.

Results: Onset times of motor and sensory block were shorter in the bupivacaine plus S(+) ketamine group. Incomplete motor block of the lower extremities was seen in 80% of the patients in bupivacaine plus S(+) ketamine group. Duration of complete motor block and spinal analgesia was shorter in the bupivacaine plus S(+) ketamine group. There was no significant difference in arterial pressure. Heart rate decreased after spinal anaesthesia in the bupivacaine plus S(+) ketamine group and was significantly lower until the end of anaesthesia. The incidence of adverse effects was not different between groups.

Conclusions: Intrathecal S(+) ketamine administered with a low dose of bupivacaine provides shorter motor and sensory block onset time, shorter duration of action and less motor blockade in elderly males.

Summary

Background and objective: Intrathecal injections of the benzodiazepine midazolam have been reported to cause antinociception in animals and pain relief in human beings, including the potentiation of opioid analgesia. This study compared the efficacy of the addition of midazolam to a mixture of buprenorphine and bupivacaine used for spinal anaesthesia.

Methods: The study was prospective, randomized, and observer blinded. It involved 60 patients (30 per group), ASA I and II, age 20–40 yr, undergoing minor and intermediate lower abdominal surgery under spinal anaesthesia. Patients were randomized into two groups: the control group received a spinal injection of hyperbaric bupivacaine (15 mg) plus buprenorphine (0.15 mg) and the experimental group received a spinal injection of the same two drugs and doses but supplemented with intrathecal midazolam (2 mg).

Results: The duration of postoperative analgesia in the control group was 9.24 ± 2.57 h (mean ± SEM), and 21.33 ± 12.69 h in the midazolam treated group (P < 0.001). Patients treated with intrathecal midazolam had better pain relief judged by visual analogue score on coughing (P = 0.0013) and a nursing mobility score (P < 0.0001). Adverse effects were minor and their incidence was similar in both groups.

Conclusions: We conclude that intrathecal midazolam 2 mg improves the quality and duration of postoperative pain relief afforded by intrathecal buprenorphine and bupivacaine.

Summary

Background and objective: Transurethral prostatectomy is routinely performed under spinal anaesthesia. This technique can cause hypotension, which is particularly undesirable in the elderly. The objective was to compare spinal anaesthesia for transurethral prostatectomy using hyperbaric bupivacaine 15 mg (control group) and hyperbaric bupivacaine 10 mg (limiting spread by maintaining the upright position for 15 min) and fentanyl 25 μg (fentanyl group) in terms of haemodynamic and pulmonary function.

Methods: Thirty ASA I–III patients were randomly selected and underwent spinal anaesthesia with either hyperbaric bupivacaine 15 mg (immediately positioned supine) or hyperbaric bupivacaine 10 mg (upright for 15 min) and fentanyl 25 μg.

Results: The greatest changes in mean arterial pressure (P = 0.9), ephedrine requirements (P = 0.8) and mean maximum change in forced vital capacity (P = 0.5) were similar in both groups.

Conclusions: The addition of fentanyl 25 μg to bupivacaine 10 mg and limiting the spread of the block does not improve either haemodynamic or pulmonary function compared with bupivacaine 15 mg in patients undergoing transurethral prostatectomy.