At caesarean section under regional anaesthesia, it is essential to test sensory block with light touch before allowing surgery to start.
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Anesthesia, Conduction↗
Biomedical subjects
I F Russell
Publications and source records attributed to I F Russell.
A randomised comparison of 0.5% bupivacaine with a lidocaine/epinephrine/fentanyl mixture for epidural top-up for emergency caesarean section after "low dose" epidural for labour.
BACKGROUND: When extending a fentanyl-containing, low-dose labour epidural for emergency caesarean section it has been shown that there is no difference in time to surgical readiness between plain bupivacaine 0.5% and mixtures of lidocaine/epinephrine or lidocaine/bupivacaine/epinephrine. However, it is not known whether adding fentanyl to the lidocaine/epinephrine mixture would increase speed of onset or improve the efficacy of the mixture when topping up for an emergency caesarean section. METHODS: In a prospective, single blind study we compared plain 0.5% bupivacaine with a lidocaine/epinephrine/fentanyl mixture for extending previous low-dose epidural analgesia for emergency caesarean section in 68 patients. RESULTS: There was a significantly longer median preparation time for the mixture than for the single drug (3.0 v 1.25 min: P < 0.0005). The median onset time for block of T7 to touch from the start of the top-up was 13.8 min for the mixture and 17.5 min for plain bupivacaine. This difference was not statistically significant and was offset by the longer preparation time. No general anaesthetics were required for poor blocks and the need for other intraoperative supplementation was not significantly different between the groups (bupivacaine 5/34, lidocaine mixture 2/26). CONCLUSIONS: The use of a lidocaine/epinephrine/fentanyl mixture conferred no clear statistically significant benefit over the use of plain 0.5% bupivacaine when used to extend fentanyl containing low-dose labour epidural analgesia for emergency caesarean section, but the lidocaine solution is cheaper and less toxic than the alternatives.
Adult↗
The Narcotrend 'depth of anaesthesia' monitor cannot reliably detect consciousness during general anaesthesia: an investigation using the isolated forearm technique.
BACKGROUND: During general anaesthesia in the presence of neuromuscular blocking drugs clinical criteria cannot detect the presence of consciousness. Various 'depth of anaesthesia' monitors are available which claim to prevent consciousness and/or reduce anaesthetic drug use. This study uses the Narcotrend anaesthesia brain monitor to guide anaesthetic administration but at the same time checks for the presence of intra-operative consciousness by using the 'isolated forearm' technique throughout the whole surgical/anaesthetic procedure. METHODS: Twelve women presenting for major gynaecological surgery under general anaesthesia, which included the use of neuromuscular blocking drugs, had a target controlled infusion of propofol adjusted according to the anaesthetic 'stage' indicated by a Narcotrend 'Depth of Anaesthesia Monitor'. Throughout surgery the isolated forearm technique was used to detect for the presence of consciousness at 1 min intervals. RESULTS: Isolated forearm responses to commands occurred in all 12 patients at some time during surgery, frequently in the absence of any significant changes in the usually monitored clinical variables. Overall, the 12 patients responded a total of 92 times during surgery. Only 41 (45%) responses were associated with an increase in the Narcotrend stage to a level suggesting consciousness (above stage C(0)). For the remaining responses, either there was no significant increase in the Narcotrend stage (above C(0)) or there was no change at all in the Narcotrend stage before, during, or after the patient responded to the taped command. CONCLUSIONS: The Narcotrend was unable to differentiate reliably between conscious and unconscious patients during general anaesthesia when neuromuscular blocking agents were used.
Acoustic Stimulation↗
How competent are obstetric and gynaecology trainees in managing maternal cardiac arrests?
The recent Confidential Enquiry (2000-2002) has emphasised 'emergency drills for maternal resuscitation should be regularly practised in clinical areas in all maternity units'. It was therefore planned to assess the knowledge of airway management and ventilation among obstetrics and gynaecology trainees in the Yorkshire Deanery (Training Region). Questionnaires were given to trainees attending the Modular Training Programme and were collected on the same day. A total of 71 questionnaires were collected which represents 62% of the 113 trainees in Yorkshire region. Replies were received from 39 registrars, 27 Senior House Officers (SHO), four Senior SHOs (SSHO) and one clinical fellow. MRCOG Part 1 was passed by 52% and 36% of trainees had MRCOG Part 2. A total of 69% of trainees did not know that chin lift opens the airway in some 70 - 80% of patients; 50% of trainees were not aware why jaw thrust is preferred over chin lift; 76% of the trainees knew the most common cause of airway obstruction in a patient with an altered level of consciousness--the tongue falls back and obstructs the pharynx ('swallowing the tongue'). Knowledge of the main cause of airway obstruction was good among obstetrics and gynaecology trainees, but their understanding of how to manage this was found to be relatively poor. Attendance at a local Basic Life Support course should be compulsory for obstetric and gynaecology trainees early in their career.
Education, Medical↗
Outcomes of severe pre-eclampsia/eclampsia in Yorkshire 1999/2003.
OBJECTIVE: To establish the risk of serious complications from severe pre-eclampsia and eclampsia in a region using a common guideline for the management of these conditions. DESIGN: A five-year prospective study. SETTING: Sixteen maternity units in Yorkshire. POPULATION: All women managed with severe pre-eclampsia and eclampsia. METHODS: A common guideline was developed for the management of women with these conditions. A network of midwives prospectively collected outcome data. MAIN OUTCOME MEASURE: Incidence of the conditions and serious complication rates. RESULTS: A total of 210,631 women delivered in the 16 units between 1 January 1999 and 31 December 2003. One thousand eighty-seven women were diagnosed with severe pre-eclampsia or eclampsia (5.2/1000). One hundred and fifty-one women had serious complications including 82 women (39/10,000) having eclamptic seizures and 49 women (23/10,000) requiring ICU admission. There were no maternal deaths but 54 out of 1145 babies died before discharge, giving a mortality rate of 47.2/1000. Of the 82 cases of eclampsia, 45 occurred antenatally (55%), 18 before admission to the maternity unit. Eleven cases occurred in labour (13%), including 1 during a caesarean section, and 26 cases occurred following delivery (32%). Twenty-five women developed pulmonary oedema (2.3% of cases) and six women required renal dialysis (0.55% of cases). One hundred and sixty-five (15%) required no antihypertensive therapy and 489 (53%) of the remainder required only oral therapy. Two hundred and one (18.5%) required more than one drug. CONCLUSION: A regional guideline for severe pre-eclampsia and eclampsia can be developed and implemented. Its use may contribute to a low rate of serious complications.
Anticonvulsants↗
Weight adjusted spinal anaesthesia for Caesarean section.
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Anesthesia, Obstetrical↗
A comparison of cold, pinprick and touch for assessing the level of spinal block at caesarean section.
The sensory block levels of 102 women undergoing caesarean section under spinal anaesthesia were assessed by four different methods: sharp pinprick (Neurotip tester pin), cold (ethyl chloride spray), touch (Neurotip tester pin), touch (ethyl chloride spray). While the data indicate a median difference of some 2 segments between the levels of block assessed by sharp pinprick or cold, and touch, there was no constant relationship between these levels of block within the group nor within individual patients: variable and at times very large differences in the levels of block assessed among these modalities existed: up to 10 segments (pinprick - touch); 11 segments (cold - touch). For any one individual, it is not possible to predict the level of block to touch from a known level of block to sharp pinprick or cold. To facilitate comparison of results across future studies it is suggested that block levels to touch sensation should always be reported. The results suggest that, for clinical purposes, there is no difference in outcomes whether Neurotip touch or ethyl chloride spray touch sensations are used. When using diamorphine 100 micrograms/mL mixed with bupivacaine 0.5% w/v in 8% dextrose, no patient felt any pain or discomfort provided the block to Neurotip or ethyl chloride touch sensations included T6 or above.
Adult↗
A randomised double-blind comparison of epidural fentanyl versus fentanyl and bupivicaine for pain relief in the second stage of labour.
OBJECTIVES: To compare the effectiveness of two different methods for epidural analgesia in the second stage of labour-fentanyl alone versus the usual mixture of bupivicaine and fentanyl. DESIGN: A double-blind, randomised, controlled trial. SETTING: An English maternity hospital. SAMPLE: Eighty nulliparous women in the second stage of labour. METHODS: After successful institution of epidural analgesia with a continuous infusion of bupivicaine/fentanyl mixture in the first stage of labour, the patients were randomised at full dilatation to receive either continuation of the same solution or a change to a fentanyl-only solution given at the same rate. MAIN OUTCOME MEASURES: Mode of delivery, duration of the second stage and quality of analgesia. RESULTS: There was no difference in the number of instrumental deliveries (30%vs 27.5%) or the duration of the second stage (141 vs 147 minutes) between the bupivicaine/fentanyl and fentanyl groups, respectively. The bupivicaine/fentanyl group demonstrated a lower need for rescue epidural analgesia (1 vs 6, RR 0.2, 95% CI 0.02-1.3) and significantly fewer high pain scores (11 vs 20, RR 0.6, 95% CI 0.3-1.0). CONCLUSION: Second stage epidural analgesia with fentanyl did not alter delivery outcomes or labour duration but resulted in poorer analgesia.
Adult↗
A randomised controlled trial of the closure or non-closure of peritoneum at caesarean section: effect on post-operative pain.
OBJECTIVE: To compare the analgesic requirement in the post-operative period after closure or non-closure of the peritoneum at the caesarean delivery with a standardised anaesthetic and surgical technique. DESIGN: A randomised double-blind controlled trial was performed on 100 women who underwent elective caesarean delivery. MAIN OUTCOME MEASURES: Analgesic requirement assessed by morphine usage via patient controlled analgesia pump over the first 24-hour period after surgery, oral analgesia used during the first four days, postoperative pain assessed by a visual analogue scale and a verbal rating scale, and patient satisfaction assessed by verbal rating scale were the main outcome measures. RESULTS: Pain scores at 24 hours were similar in both groups (43.5 in closure and 40.5 in non-closure) but during the first 24 hours the non-closure group had used significantly less morphine than the closure group (0.64 mg/kg of body weight vs 0.82 mg/kg, P = 0.04). The patients in non-closure group had significantly higher satisfaction scores after 24 hours than the closure group. CONCLUSION: Non-closure of both visceral and parietal peritoneum at the caesarean section produces a significant reduction in the post-operative use of patient controlled analgesia pump morphine and significantly higher patient satisfaction at 24 hours post-operatively.
Adult↗
Assessing the block for caesarean section.
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Editorial↗
Absence of memory for intra-operative information during surgery with total intravenous anaesthesia.
While using the isolated forearm technique, we wished to determine whether patients who did not respond to commands during general anaesthesia with a total intravenous technique (propofol and alfentanil with atracurium) had any evidence of post-operative explicit or implicit memory. Forty women undergoing major gynaecological surgery were randomized, in a double-blind design, to hear two different tapes during surgery. Psychological tests of explicit and implicit memory were conducted within 2 h of surgery. There was no evidence of implicit or explicit memory, nor any recall, in the seven women who responded to commands during surgery. We conclude that during total intravenous anaesthesia with propofol and alfentanil, there is no evidence that learning takes place when anaesthesia is adequate. Furthermore, with this anaesthetic technique, it would seem that--provided any period of patient responsiveness is short and that unconsciousness is induced rapidly again--there is no evidence of implicit or explicit memory.
Adult↗
Effect of intrathecal fentanyl on oxytocin secretion in pregnant women not in labour.
We studied the effects of spinal intrathecal fentanyl on oxytocin secretion in 20 healthy women prior to an elective caesarean delivery at term under spinal anaesthesia. The women were randomly allocated into two groups with respect to spinal anaesthesia. Group I (n=10) received intrathecal bupivacaine (15 mg) plus fentanyl (25 microgram), and Group II (n=10) received intrathecal bupivacaine (15 mg) alone, prior to caesarean section. The two groups were comparable demographically. Altogether, ten samples of 4.5 ml of blood (taken every 60 s) were obtained before and ten samples were obtained after the intrathecal administration of the drug and establishment of the T6 block, and plasma oxytocin concentrations were assayed for each subject. Oxytocin was measured by RIA. We found no significant differences in plasma oxytocin concentrations of individual subjects before and after intrathecal injection. In addition, there were no significant differences in plasma oxytocin concentrations between the two groups when pooled samples from the subjects were compared for the pre- and post-intrathecal injection phases. We conclude that the spinal intrathecal administration of fentanyl does not suppress oxytocin secretion in pregnant women who are not in labour at term.
Adult↗
A survey of anaesthetic techniques used for caesarean section in the UK in 1997.
A prospective survey of anaesthesia for caesarean section was performed for the year 1 January to 31 December, 1997. Two hundred and fifty maternity hospitals were sent questionnaires from which 129 responses were obtained. The data provided information on anaesthesia for 60 455 caesarean sections. Overall 78% of sections were performed with regional anaesthesia: 47% single shot spinal; 22% epidural; 9% combined spinal epidural (CSE); 22% general anaesthesia. For elective caesarean sections (39% of all sections) regional anaesthesia was used for 87% of cases: 68% single shot spinal; 3% epidural; 15% CSE; 13% general anaesthesia. For emergency procedures regional anaesthesia was used for 72% of cases: 34% single shot spinal; 34% epidural; 4% CSE; 28% general anaesthesia. There was a wide range of regional anaesthesia use among the units, varying from an overall rate of 95% at one extreme to 41% at the other. Similarly, there was a wide range of conversion of regional anaesthesia to general anaesthesia, varying from 0% to 88%. Overall, 10.6% of the general anaesthetics were the result of regional to general anaesthesia conversion.
Journal Article↗
Caesarean section for placenta praevia: a retrospective study of anaesthetic management.
A retrospective survey of anaesthesia for Caesarean section (CS) for placenta praevia was performed, covering the period between January 1, 1984 and December 31, 1998. Three hundred and fifty consecutive cases of placenta praevia were identified. Overall a regional technique was used 60% of the time. Five women had a placenta accreta which required Caesarean hysterectomy: one had general anaesthesia (GA) throughout and four initially received a single-shot spinal injection. Of these latter four cases, two were converted to GA during the hysterectomy and two continued with spinal anaesthesia throughout. Two other women (both GA), suffered postoperative thrombotic episodes (one pulmonary embolus and one cerebral thrombosis) but made full recoveries. Control of blood pressure when using regional anaesthesia (RA), even in the presence of considerable haemorrhage, was not a problem. Statistical regression models indicated that RA was associated with a significantly reduced estimated blood loss and reduced need for blood transfusion. This retrospective survey finds no data to support the much quoted aphorism that RA is contraindicated for CS in the presence of placenta praevia.
Anesthesia, Epidural↗
A randomised, controlled study of uterine exteriorisation and repair at caesarean section.
OBJECTIVE: To determine the surgical and anaesthetic benefits and problems associated with the practice of routine exteriorisation of the uterus to facilitate repair at caesarean section. DESIGN: A randomised controlled study of women undergoing caesarean section. After establishment of anaesthesia, women were randomised to either exteriorisation and uterine repair or suture of the uterus in the abdomen. SETTING: A maternity hospital in the United Kingdom. MAIN OUTCOME MEASURES: Peri-operative haemoglobin change, duration of operation, maternal morbidity and length of hospital stay. Intra-operative pain, nausea, vomiting, pulling or tugging sensations were secondary outcome measures. RESULTS: Three hundred and sixteen women were randomised, of whom 288 were subsequently analysed (139 women in whom the uterus was exteriorised and 149 where the uterus was not exteriorised). Exteriorisation of the uterus, an elective caesarean section and a spinal or general anaesthesia each had a statistically significant association with reduced blood loss (P < 0.05). There were no statistically significant differences between the two groups with regard to intra-operative complications or pain, nor were there any statistically significant difference in post-operative wound sepsis, pyrexia, deep vein thrombosis, blood transfusion or length of hospital stay. CONCLUSION: With effective anaesthesia, exteriorisation of the uterus for repair following caesarean delivery is not associated with significant problems and is associated with less blood loss.
Adult↗
Volume preload: lack of effect in the prevention of spinal-induced hypotension at caesarean section.
A randomized double-blind study of 40 women was performed to compare blood pressure changes between two groups of women following induction of spinal anaesthesia for elective caesarean section. One group received a 1 L Ringer's solution preload, administered over 10 min, before spinal anaesthesia while the other group received no preload. In both groups a prophylactic infusion of ephedrine (60 mg in Ringer's solution 1000 ml) was started immediately following intrathecal injection of local anaesthetic. There was no significant difference either in the ephedrine requirements or the incidence of hypotension between the two groups. There were no differences between the groups in terms of neonatal outcome as assessed by Apgar score, umbilical arterial and venous blood pH, and Neonatal Adaptive Capacity Scores. When ephedrine is infused prophylactically immediately following spinal anaesthesia for elective caesarean section, a 1000 ml crystalloid preload confers no advantages in terms of maternal blood pressure control or neonatal outcome.
Clinical Trial↗
Intrathecal diamorphine compared with morphine for postoperative analgesia after caesarean section under spinal anaesthesia.
A randomized, double-blind study of 40 women was performed to compare patient controlled anaesthesia (PCA) morphine requirements after spinal anaesthesia for elective Caesarean section. The women received 0.2 mg of either morphine or diamorphine mixed with 0.5% bupivacaine in 8% dextrose. There were no significant differences between the groups in terms of VAS for pain, either while supine or trying to turn over. The median VAS for itching were significantly higher in the morphine group at 3, 4, 6, 8 and 12 h. Similarly, the VAS for drowsiness were significantly higher in the morphine group at 6 and 8 h. Overall there was no difference in the 24-h PCA morphine demands between the two groups (diamorphine patients 5.5 mg, morphine patients 5.0 mg.
Adult↗