International journal of obstetric anesthesia
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Int J Obstet Anesth · Jan 1993
Is opioid loading necessary before opioid/local anaesthetic epidural infusion? A randomized double-blind study in labour.
The effects of two different epidural loading doses administered before starting an opioid/low dose local anaesthetic infusion were examined in a randomized double-blind study during labour. Forty mothers were given either 10 ml 0.25% plain bupivacaine or 10 ml 0.125% plain bupivacaine containing 5 mcg of sufentanil followed in all cases by epidural infusion of 0.08% plain bupivacaine containing 0.2 mcg/ml of sufentanil, which was continued into the second stage. The quality of analgesia did not differ significantly between the groups in either the first or the second stage of labour: in each group 75% of women required 0 or 1 top-up during labour and verbal numerical pain scores were similar. ⋯ There was no difference in the degree of maternal satisfaction assessed 24 hours after delivery, with 80% of women in each group awarding the maximum verbal numerical score for their satisfaction with epidural analgesia. The incidence of maternal side effects (nausea, vomiting, drowsiness and pruritus) was similar in the 2 groups as was neonatal outcome, assessed by Apgar and neurological and adaptive capacity scores and umbilical artery and vein pH. We conclude that opioid loading before opioid/low-dose bupivacaine epidural infusions is unnecessary.
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Int J Obstet Anesth · Jan 1993
Patient controlled epidural analgesia during labour: choice of solution.
Epidural characteristics, when using different solutions for patient controlled epidural analgesia (PCEA), were compared in a randomised, blinded study in labour. Women in group 1 (n=23) self-administered 0.25% plain bupivacaine, in group 2 (n=23) 0.125% plain bupivacaine plus fentanyl 3 microg/ml and in group 3 (n=20) 0.0625% bupivacaine with adrenaline 1:250,000 plus fentanyl 3 microg/ml. ⋯ The rate of bupivacaine utilisation was significantly higher in group 1 compared to groups 2 and 3 and lower in group 3 compared to 1 and 2 (median+interquartile range: 16+11-21 vs 9+6-11 vs 4+3-8 mg/hr, P<0.0002). Although all solutions provided effective pain relief for PCEA during labour, the use of a low-dose bupivacaine-fentanyl combination offers clinical advantages and further evaluation of such solutions is warranted.
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It is recommended that a cricoid pressure (force) of 40 N should be applied to prevent regurgitation. The tolerance of incremental levels of cricoid pressure was assessed in 22 conscious volunteers. Each level of cricoid pressure was applied for 20 s using a cricoid yoke. ⋯ Nine subjects complained of breathing difficulties at cricoid forces of 35 N or above; 2 had complete airway obstruction. A, cricoid force of over 20 N is likely to be poorly tolerated by the awake patient. It is recommended that a force of 20 N should be maintained before loss of consciousness and the full force of 40 N be reserved for the onset of general anaesthesia; the assistant can practise these levels on a set of weighing scales.
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Int J Obstet Anesth · Sep 1992
Successful cardiopulmonary resuscitation of a parturient with amniotic fluid embolism.
A case of presumed amniotic fluid embolism is presented. Diagnosis is based on clinical findings in a 21-year-old parturient, who was admitted to hospital at 39 weeks gestation. During labor the patient became dyspneic and cyanotic, had convulsions and finally suffered a cardiac arrest. ⋯ Following delivery of the baby the heart rhythm returned to normal. The prolonged resuscitation produced serious neurological sequelae in both mother and infant in the first few months following delivery, though with complete long-term recovery. This case report highlights the importance of displacing the uterus laterally and performing an emergency cesarean section during resuscitation.