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L Irestedt

Publications and source records attributed to L Irestedt.

At least 19 recordsLinked to original sources
PubMed2005

Colloid vs. crystalloid preloading to prevent maternal hypotension during spinal anesthesia for elective cesarean section.

BACKGROUND: Hypotension associated with spinal anesthesia for cesarean section is still a clinical problem. Colloid solutions seem preferable to crystalloid solutions for preloading. In most studies the overall rate of hypotension is reported. Few studies have, however, investigated the maternal and neonatal consequences of different levels of maternal hypotension. METHODS: In this randomized, double-blinded study 110 patients presenting for elective cesarean section received either 1000 ml acetated Ringer's solution or 1000 ml 3% dextran 60 solution immediately before spinal anesthesia. The effect on overall hypotension, clinically significant hypotension (hypotension associated with maternal discomfort defined as nausea, retching/vomiting, dizziness or chest symptoms) and severe hypotension (systolic arterial pressure <80 mmHg) was studied. RESULTS: Dextran reduced the incidence of overall hypotension from 85 to 66% (P=0.03), reduced the incidence of clinically significant hypotension from 60 to 30% (P=0.002) and reduced the incidence of severe hypotension from 23 to 3.6% (P=0.004) compared to Ringer's solution. There were neither differences in neonatal outcome between treatment groups nor between neonates grouped after severity of maternal hypotension. CONCLUSION: Clinically significant hypotension seems to be a more suitable outcome variable than overall hypotension. The protective effect of the colloid solution increased with increased severity of hypotension.

Adult↗
PubMed2004

Four cases of the ex utero intrapartum treatment (EXIT) procedure: anesthetic implications.

The ex utero intrapartum treatment (EXIT) procedure is a method of maintaining utero-placental circulation during cesarean section to gain time to secure a potentially obstructed fetal airway. Four cases of the EXIT procedure are described with special reference to the maternal anesthetic technique. Deep volatile anesthesia (approximately 2 MAC) with isoflurane or sevoflurane for a prolonged period of time, in three cases in combination with an intravenous nitroglycerin infusion, was used to ensure a fully relaxed uterus during the procedure. All mothers were maintained hemodynamically stable with preserved utero-placentary perfusion. It was possible to intubate the tracheas of two fetuses, whereas in the other two tracheostomies had to be performed. Fetal gas exchange was not negatively affected during the EXIT procedure as evidenced by normal blood gas values in the umbilical artery at the time of delivery. After reducing the concentration of volatile anesthetic, delivery of the neonate and administration of oxytocin, uterine contractility was promptly re-established and there were no signs of uterine atony in the postoperative period. All four neonates survived the procedure without complications.

Adult↗
PubMed2000

[Review of claims from the Patient Insurance: spinal anesthesia is not completely without risks].

The Patient Injury Claims Department in Sweden grants compensation to patients who have incurred injury in the national health service system. All claims involving spinal and epidural anaesthesia were studied during the period 1997-1999. Serious neurological complications were behind 29 out of 65 claims. These occurred more frequently after epidural anaesthesia (1:4,000) than after spinal anaesthesia (1:13,000) with the exclusion of obstetric epidural anaesthesia (1:40,000). Epidural haematoma occurred in 1:30,000 after epidural anaesthesia, in 1:200,000 after spinal anaesthesia. One epidural abscess occurred in 60,000 epidural anaesthesias, while five cases of meningitis occurred after spinal anaesthesia (1:40,000).

Analgesia, Epidural↗
PubMed2000

Neurological complications in obstetric regional anaesthesia.

Neurological complications after obstetric central neural blocks are rare events. Although central neural blockade does cause neurological complications, there must be awareness that neurological deficits may either develop spontaneously (e.g. epidural abscess/haematoma) or as a result of the labour and delivery process (maternal obstetric palsies). We have attempted to review as completely as possible the published survey and case reports in the English literature on neurological complications of obstetric regional blockade obtained from Medline spanning the period 1966 to November 1998. We also performed cross-checking of our references to find important missing articles, e.g. papers published in journals not included in Index Medicus at the time of publication, such as the International Journal of Obstetric Anesthesia. We wish to provide some insight to the incidences, pathophysiology, clinical features, investigations, treatment and prognosis of these complications. Maternal obstetric palsies and case reports of spontaneous epidural abscess/haematoma are also discussed. It is often difficult, if not impossible, to determine the exact aetiology, but unfortunately for the anaesthetists, regional blockade is usually incriminated till proven otherwise. Although we cannot eliminate the occurrence of neurological complications completely, preventive measures can still be taken to decrease their incidence (e.g. aseptic technique). There must also be regular monitoring after neural blockade for the development of neurological complications. Early diagnosis and prompt appropriate treatment will usually lead to complete resolution of the neurological deficit even in cases of epidural haematoma/abscess.

Journal Article↗
PubMed1999

Cauda equina syndrome after spinal anaesthesia with hyperbaric 5% lignocaine: a review of six cases of cauda equina syndrome reported to the Swedish Pharmaceutical Insurance 1993-1997.

Six cases of cauda equina syndrome with varying severity were reported to the Swedish Pharmaceutical Insurance during the period 1993-1997. All were associated with spinal anaesthesia using hyperbaric 5% lignocaine. Five cases had single-shot spinal anaesthesia and one had a repeat spinal anaesthetic due to inadequate block. The dose of hyperbaric 5% lignocaine administered ranged from 60 to 120 mg. Three of the cases were most likely caused by direct neurotoxicity of hyperbaric 5% lignocaine. In the other 3 cases, direct neurotoxicity was also probable, but unfortunately radiological investigations were not done to definitely exclude a compressive aetiology. All cases sustained permanent neurological deficits. We recommend that hyperbaric lignocaine should be administered in concentrations not greater than 2% and at a total dose preferably not exceeding 60 mg.

Adult↗
PubMed1998

Traditional analgesic agents: are parenteral narcotics passé and do inhalational agents still have a place in labour?

Systemic labour pain treatment with opioids and inhaled nitrous oxide has for many decades frequently been used in medically developed countries. Self-administered nitrous oxide (50% in oxygen) has never gained the same popularity in the USA as in the UK or Scandinavia but the use of opioids, mainly pethidine, has generally been widespread in spite of well-known negative effects on the postnatal adaptation of the newborn. Since the often very intense labour pain seems to respond very poorly even to highly sedating doses of parenteral opioids, their frequent use during delivery and parturition has to be questioned. Self-administered inhalation of nitrous oxide 50% in oxygen also has a limited efficacy for relieving labour pain but because it is mainly devoid of adverse effects on the baby or on the parturient its future use in obstetrics can be defended more easily, either as a sole agent in women with low labour pain scores or in early labour preceding epidural analgesia.

Administration, Inhalation↗
PubMed1998

Obstetric outcome following epidural analgesia with bupivacaine-adrenaline 0.25% or bupivacaine 0.125% with sufentanil--a prospective randomized controlled study in 1000 parturients.

BACKGROUND: Epidural analgesia (EDA) is the most efficient method for pain relief during labour, but there is still a debate as to whether it interferes with the normal process of delivery. Some authors argue that the incidence of instrumental deliveries, Caesarean section, malrotation and protracted labour is increased in parturients receiving EDA. METHODS: 1000 parturients were prospectively randomized to receive EDA either with a high dose of local anaesthetic (0.25% bupivacaine with adrenaline = HD) or with a low dose (0.125% bupivacaine with sufentanil 10 micrograms = LD). RESULTS: The incidence of instrumental delivery and Caesarean section and the need for oxytocin was reduced in the LD compared to HD group. The delivery time was similar with HD and LD among primiparous, but decreased significantly among multiparous in the LD group. The incidence of malrotation was low in both groups. The quality of analgesia was equal during the first stage in the 2 groups, but was lower in the LD group during the second stage. More parturients in the LD group ambulated, but this did not affect the incidence of instrumental delivery. CONCLUSION: It is concluded that a lower dosage of bupivacaine combined with sufentanil in epidural analgesia significantly improves the obstetric outcome as compared to a higher dosage of bupivacaine with adrenaline using intermittent bolus technique.

Analgesia, Epidural↗
PubMed1998

Pharmacokinetics and clinical effect during continuous epidural infusion with ropivacaine 2.5 mg/ml or bupivacaine 2.5 mg/ml for labour pain relief.

BACKGROUND: Ropivacaine has shown less systemic toxicity than bupivacaine, and comparatively low muscle-blocking properties could constitute another advantage when used epidurally for obstetric pain relief. We aimed primarily to compare maternal and foetal drug disposition following continuous epidural infusion of ropivacaine or bupivacaine. METHODS: Twenty-four full-term, nulliparous women were randomized to continuous epidural infusion (10 ml/h) of ropivacaine 2.5 mg/ml or bupivacaine 2.5 mg/ml for labour pain relief in a double-blind, parallel-group design. Maternal blood samples were collected up to 24 h after the end of infusion as well as taken from the umbilical cord at the time of delivery. Sensory and motor block as well as analgesia were assessed. All the women were monitored by cardiotocography and neonatal assessment was performed. RESULTS: The sensory block was adequate for both drugs. Higher plasma levels (total and free) were seen with ropivacaine, although the infusion with bupivacaine continued on average for about 2 hours longer. However, the ratios between maternal and umbilical blood concentrations were similar for both drugs. Normal neonatal Apgar and neonatal adaptive capacity scores (NACS) were found in both groups. CONCLUSION: A continuous epidural infusion of 25 mg/h ropivacaine or bupivacaine both produced good labour pain relief. Higher total and free plasma concentrations were seen for ropivacaine. The ratios between maternal and umbilical plasma levels were similar for both drugs.

Adult↗
PubMed1997

Increased cerebrospinal fluid concentration of aspartate but decreased concentration of nitric oxide breakdown products in women experiencing visceral pain during active labour.

The aim of the present study was to investigate some putative neurotransmitters involved in nociception and pain in parturients during active labour experiencing intense visceral pain. The concentration of the excitatory amino acid aspartate was significantly increased, and there was a tendency for an increase in glutamate, in lumbar cerebrospinal fluid (CSF) of parturients in active vaginal labour compared with control patients without pain subjected to elective caesarean section. The CSF concentration of the nitric oxide breakdown product nitrate was significantly decreased in parturients compared with control patients and healthy volunteers. No significant differences in the concentrations of substance P, substance P-endopeptidase or met-enkephalin were detected between parturients and controls. Our data suggest a paradoxical negative relationship between CSF concentrations of excitatory amino acids and nitric oxide in labour pain. The mechanisms behind this finding is unclear at present.

Adult↗
PubMed1997

Anesthetic quality during cesarean section following subarachnoid or epidural administration of bupivacaine with or without fentanyl.

BACKGROUND: It is often assumed that subarachnoid administration of local anesthetics produces a more profound blockade than epidural anesthesia. Furthermore, the addition of fentanyl has been reported to increase preferentially intraoperative analgesia. In the present study we set out to study these two issues in a randomized and controlled study with respect to perceived pain and discomfort during surgery and postoperative pain. METHODS: In the present study, 100 parturients subjected to elective cesarean section, 34 nullipara and 66 multipara, received one out of four combinations of the local anesthetic bupivacaine and the opioid fentanyl; group A--bupivacaine 12.5 mg + 10 micrograms fentanyl subarachnoidally, group B--bupivacaine 12.5 mg + saline subarachnoidally, group C--bupivacaine 100 mg + 100 micrograms fentanyl epidurally, group D--bupivacaine 100 mg + saline epidurally; N = 25 in each group. Pain intensity and discomfort during surgery was assessed with a visual analogue scale (VAS). Postoperative pain intensity and need for analgesics postoperatively, ketobemidone, was registered for 24 h following surgery. RESULTS: Intraoperative pain intensity and discomfort did not differ significantly between parturients in any of the four groups Postoperative pain was significantly more intense in parturients receiving local anesthetics subarachnoidally as compared to the epidural groups during the first 6-h period. This difference was also reflected in a significantly increased consumption of analgesics during this period. No significant differences between the groups were observed with regard to hemodynamics (blood pressure), respiration (oxygen saturation) or other effects such as nausea or itching. All neonates had normal Apgar and neonatal adaptive capacity scores (NACS). CONCLUSION: We conclude that subarachnoidal (12.5 mg) and epidural (100 mg) injections with bupivacaine both produced adequate anesthetic quality in women undergoing elective cesarean section. The addition of fentanyl (10 micrograms subarachnoidally or 100 micrograms epidurally) did not significantly improve the quality of these already profound blockades.

Adult↗
PubMed1997

Antinociceptive effect of perioperative adenosine infusion in abdominal hysterectomy.

BACKGROUND: Adenosine (ADO), and stable analogs thereof, have been shown to exert antinociceptive action in cutaneous and deep somatic pain under experimental and clinical conditions in animals and in humans. The aims of this randomized double-blind placebo-controlled study were to evaluate if a low dose of intravenous (i.v.) ADO could reduce the requirements of volatile anesthetic and postoperative opioid in connection to hysterectomy, where visceral nociception significantly contributes to pain. METHODS: Forty-three women, age 32-65 years, ASA I and II, scheduled for abdominal hysterectomy, were assigned to receive an i.v. infusion of either adenosine, 80 micrograms.kg-1.min-1, or placebo during surgery. Anesthesia was maintained with isoflurane (ISO)/N2O/ O2 inhalation. Postoperatively, a reduced dose of 40 micrograms.kg-1.min-1 was continued for 3 h. RESULTS: The end-tidal (ET-) ISO was equal between groups before surgery. During surgery, the ISO requirement was increased, compared to the preoperative level, in the placebo group, while the requirement declined in the ADO group. The overall ISO requirement in the ADO group was reduced by 36% (P < 0.002). The first 24 h postoperative opioid requirement, with equal resting pain in both groups, was 18% (P < 0.05) lower in the ADO group. CONCLUSION: A low dose of perioperative adenosine infusion in abdominal hysterectomy reduces the requirements of volatile anesthetic and postoperative opioid analgesic.

Adenosine↗
PubMed1997

Ropivacaine 7.5 mg/ml for elective caesarean section. A clinical and pharmacokinetic comparison of 150 mg and 187.5 mg.

BACKGROUND: The new, long-acting local anaesthetic ropivacaine has shown less systemic toxicity than bupivacaine and a concentration of 7.5 mg/ml can therefore be used for epidural anaesthesia in Caesarean section. The present pilot study was undertaken to find indications for an optimal dosage by comparing the clinical effects, quality of anaesthesia and pharmacokinetics of ropivacaine 150 mg (lower dose = LD) vs 187.5 mg (higher dose = HD) for women undergoing elective Caesarean section under epidural anaesthesia. METHODS: Sixteen full-term women scheduled for elective Caesarean section in two equal-sized consecutive groups received 20 or 25 ml ropivacaine epidurally in this non-randomised, open study. Study parameters included sensory and motor blockade, circulatory response, intraoperative pain and discomfort, neonatal evaluation and pharmacokinetic determinations. RESULTS: Block height varied between T5 and T2 in the LD group, whereas the HD group produced 4 unnecessarily high blocks (C8 in 3 women and C7 in 1 woman). Surgical anaesthesia was excellent in both groups. Circulatory stability was pronounced in the LD group (no ephedrine given), while 4 women required ephedrine in the HD group. Neonatal outcome as judged by Apgar scores; umbilical blood gas determinations and NACS scores were excellent in both groups. The plasma concentration-time profiles indicated linearity in the concentration range studied, with similar clearance values to those reported previously. Placental drug equilibrium was rapid; however, the foetal drug exposure depended on intrauterine exposure time. CONCLUSIONS: 20-25 ml ropivacaine 7.5 mg/ml produced very satisfactory conditions for elective Caesarean section under epidural anaesthesia. In this small population, 150 mg ropivacaine seemed optimal, while 187.5 mg produced unnecessarily extended block height in 50% of the women.

Adult↗
PubMed1997

Effects of prostaglandin treatment and paracervical blockade on postoperative pain in patients undergoing first trimester abortion in general anesthesia.

BACKGROUND: The postoperative analgesic efficacy of a paracervical blockade (PCB) as an adjunct to general anesthesia (GA) during outpatient abortion (dilatation and curettage) is unclear, and the present study was initiated to evaluate if PCB is of significant importance per- or postoperatively. METHODS: Two hundred women (aged 18-49 years) were assigned to one of four groups; group 1 received vaginal prostaglandin (PG) (PGE1, gemeprost 1 mg) for softening of the cervix preoperatively and surgery was performed in GA, group 2 received preoperative PG and surgery was performed in GA + PCB; group 3 did not receive PG treatment and surgery was performed in GA and group 4 were subjected to GA + PCB without preoperative PG. RESULTS: Women receiving preoperative prostaglandin treatment (groups 1 and 2) reported significantly higher pain intensity already preoperatively, but also postoperatively as compared to patients not treated with PG. The patients subjected to prostaglandin treatment (groups 1 and 2) also had a significantly higher consumption of analgesics as compared to non-PG treated groups (3 and 4). The addition of PCB did not influence pre- and postoperative pain intensity significantly or consumption of analgesics. Patients receiving PG also reported significantly more nausea than the others although nausea was of low intensity. Patients receiving PG were, however, discharged earlier than the others from the hospital. CONCLUSIONS: Preoperative treatment of the cervix with prostaglandins was associated with significantly higher pain intensity both pre- and postoperatively, and increased need for analgesics postoperatively and more intense nausea. PCB given just before surgery did not result in significant postoperative analgesia. More efficient techniques for pain control should be developed for women subjected to first trimester abortion with preoperative PG treatment.

Abortion, Induced↗
PubMed1996

Analgesic efficacy of intravenous morphine in labour pain: a reappraisal.

The aim of the present study was to investigate the dose-related analgesic effect of intravenous (i.v.) morphine during spontaneous term first stage labour. This was an open study in 17 parturients who requested analgesia for severe labour pain. All women were given morphine i.v. in repeated doses of 0.05 mg/kg following every third contraction until a final dose of 0.20 mg/kg was reached. The decrease in overall pain intensity, from median visual analogue scale (VAS) 85 (range 52-100) to median VAS 70 (range 46-99), was clinically insignificant. The number of women experiencing back pain, however, decreased significantly following morphine. The most striking effect of morphine (7.2-18 mg) was pronounced sedation. No adverse reactions related to morphine were noted in the neonates. We conclude that i.v. morphine does not significantly reduce overall labour pain intensity. Thus, if a real analgesic effect is desired, systemically given morphine seems inappropriate and other techniques should be used.

Journal Article↗