Duration Of Epidural Analgesia Research Articles

Predictive value of neutrophil-to-lymphocyte ratio on admission for intrapartum maternal fever in parturients undergoing epidural analgesia: A retrospective cohort study using propensity score-matched analysis.

To identify the predictive value of the neutrophil-to-lymphocyte ratio (NLR) on admission for intrapartum maternal fever in parturients undergoing epidural analgesia (EA). In this retrospective cohort study, propensity score matching (PSM) was applied to address covariates. Univariate and multivariate regression analyses were implemented in sequence to find out the factors influencing intrapartum fever. The receiver operating characteristics curve was applied to determine the area under the curve (AUC) of NLR for intrapartum fever. NLR and duration of EA were independent risk factors for intrapartum fever. The AUC of the combined indicator (NLR + duration of EA) was higher than that of NLR (AUC = 0.583, 95% confidence interval [CI] 0.53-0.64) and duration of EA (AUC = 0.702, 95% CI 0.66-0.75), reaching 0.715 (95% CI 0.67-0.76; p < 0.001). NLR increased predictive performance for intrapartum fever when added to the duration of EA (net reclassification index 0.076, p = 0.022; integrated discrimination improvement 0.020, p = 0.002). NLR has limited predictive power for intrapartum fever. The combination of NLR and duration of epidural analgesia may be considered a promising predictor for intrapartum maternal fever in parturients undergoing epidural analgesia. The neutrophil-to-lymphocyte ratio is an accessible predictor for the early identification of parturients at risk of intrapartum fever.

Maternal intrapartum fever during epidural labour analgesia: Incidence and influencing factors.

The management and nursing care of women's temperature during delivery is an important part of clinical obstetrics. We aimed to evaluate maternal intrapartum fever during epidural labour analgesia to provide evidence for the management and care of women in labour. This study was conducted and reported according to the STROBE statement. Women in labour undergoing epidural labour analgesia in our hospital from 1 January 2021 to 31 August 2022 were retrospectively selected. The characteristics of women in labour with and without intrapartum fever were compared. Pearson correlation and logistic regression analysis were used to analyse the influencing factors of postpartum fever. A total of 196 women in labour were included, the incidence of maternal intrapartum fever in women in labour undergoing epidural analgesia was 27.5%. Pearson correlation analyses showed that BMI, oxytocin use, labour duration, number of vaginal examinations, time from rupture of the foetal membranes to the end of labour and duration of epidural analgesia were all correlated with the occurrence of intrapartum fever (all P < 0.05). Logistic regression analyses indicated that body mass index ≥28 kg/m2 (OR = 1.825), oxytocin use (OR = 2.082), labour duration ≥9.2h (OR = 2.613), number of vaginal examinations ≥8 (OR = 2.044-3.115), the time from rupture of the foetal membranes to the end of labour ≥250 min (OR = 2.766) and duration of epidural analgesia ≥300 min (OR = 3.106) were risk factors for intrapartum fever in women in labour undergoing epidural analgesia (all P < 0.05). Maternal intrapartum fever in women in labour undergoing epidural analgesia is common and influenced by many factors. Nurses should take early preventive care measures according to these factors during epidural analgesia in labour.

Perinatal outcomes and risk factors for epidural analgesia-associated intrapartum maternal fever: a retrospective study

Background Epidural analgesia (EA) increases the risks of maternal fever during labor, which is associated with adverse maternal and neonatal outcomes, while the risk factors for epidural-associated fever and strategies for minimizing these effects remain limited. Methods A total of 325 pregnant women were retrospectively analyzed who had attended our hospital for a vaginal in-hospital delivery, including 208 who voluntarily accepted EA and 117 who did not receive EA. During labor, 208 EA women were allocated to a fever group (n = 42, a tympanic temperature ≥37.5 °C during labor), and a no fever group (n = 166). The outcome measures included main maternal and neonatal outcomes, labor times, duration of EA and the total EA dosage administered. Results 42 out of 208 women given EA exhibited fever temperatures during labor, which were higher than in women who did not receive EA (20.19% vs. 0.85%). Maternal fever had an increased risks for conversion to surgery (adjusted odds ratio (AOR), 4.05; 95% CI, 1.44–11.39) and neonatal infections (5.13; 1.98–13.29) compared to the no fever group. While maternal fever did not increase the risks for assisted vaginal delivery, fetal distress or admission to the neonatal intensive care unit (NICU), it was predominantly associated with primiparity and lesser times of gravity. Frequent cervical examinations, the duration of first stage and total labor, and the duration of EA and its total dosage were positively correlated with the incidence of fever. Furthermore, after stratifying risk factors into subgroups, we found that more frequent cervical examinations (≥7 times) and longer duration of first stage (≥442.5 min), total labor time (≥490 min), EA (≥610.0 min) increased the risk for epidural-associated fever after adjustment for potential confounding factors. Conclusions EA increased the risk of intrapartum epidural-associated fever, which was correlated with adverse perinatal outcomes. Nulliparity, less times of gravidity, ≥7 cervical examinations, increased volume of the EA dosage, prolonged duration of EA and total labor time were risk factors for epidural-associated fever. The findings provide clinicians with insights and strategies to prevent epidural-associated fever more safely and effectively.

Effect of Intravenous Bolus Infusion of Dexmedetomidine on the Duration of Epidural Analgesia with Ropivacaine for Below Umbilical Surgeries in Adult Patients

Background: Epidural anaesthesia is one of the most popular, reliable, safe and easy neuraxial technique to administer and widely used procedure for operative anaesthesia, obstetric analgesia, postoperative pain control and chronic pain management. Epidural anaesthesia is obtained by blocking the spinal nerves in epidural space as the nerves emerge from the dura and pass in to the intervertebral foramina. Duration of epidural anaesthesia may be prolonged by addition of opioids, clonidine, neostigmine, or vasoconstrictor agents to the local anesthetic drug for better post operative pain relief. This study is designed to investigate the effect of intravenous bolus infusion of dexmedetomidine on the duration of epidural analgesia with ropivacaine for below umbilical surgeries in adult patients and its associated adverse events. Aims of study: To determine the effect of intravenous bolus infusion of dexmedetomidine on the duration of epidural analgesia with ropivacaine for below umbilical surgeries in adult patients and to assess the incidence of intra operative side-effects. Subjects and Methods: A double blind prospective randomised control study was done. Patients were allocated in to two study groups, named A and B using computer generated randomization. Results: The duration of analgesia of epidural block with isobaric 0.5% ropivacaine with intravenous infusion of saline and dexmedetomidine were compared. Post-operative pain was evaluated by Visual Analogue Scale. Duration of analgesia is the time taken from the administration of the drug to the time when the patient complains of pain of &gt; 50 in Visual Analogue Scale. The duration of analgesia was longest in patients received intravenous dexmedetomidine along with epidural ropivacaine. Conclusion: In conclusion, Intravenous infusion of dexmedetomidine added to epidural block with ropivacaine offered prolonged analgesia in below umbilical Surgeries in adult patients without increasing the incidence of adverse effects.

Epidural levobupivacaine versus a combination of levobupivacaine and dexamethasone in patients receiving epidural analgesia.

Background and Aims:The use of dexamethasone as an adjuvant to local anesthetic rarely has been described. Some studies have demonstrated the analgesic effect of local spinal and systemic corticosteroids in combination with bupivacaine. It works by decreasing inflammation and blocking transmission of nociceptive C-fibers and by stopping the ectopic discharge of the nerve. The aim of this randomized controlled trial was to compare the efficacy of epidural levobupivacaine alone versus a combination of levobupivacaine with dexamethasone for labor analgesia.Material and Methods:This prospective double-blind trial included the 60 primigravidas during vaginal delivery with a cervical dilatation ≥4 cm and 50% effacement randomly assigned to one of two groups – Group A (n=30): epidural levobupivacaine 0.125% in normal saline in a total volume of 15 mL and Group B (n=30): epidural levobupivacaine 0.125% in normal saline combined with dexamethasone 4 mg in a total volume of 15 mL. At first request of analgesia, 10 mL of 0.125% levobupivacaine was administrated through epidural catheter. Further analgesia was provided with 8 mL of 0.125% levobupivacaine hourly. Primary outcome measure was the duration of epidural analgesia. Secondary outcome measures include pain score by Visual Analog Scale score before the block and 15 min following it, the total amount of levobupivacaine used, Apgar score and umbilical vein blood gas analysis, maternal satisfaction, and side effects recorded.Results and Conclusion:The duration of epidural analgesia was significantly longer (P < 0.05) upon adding dexamethasone to levobupivacaine. Total epidural levobupivacaine consumption was significantly lower (P = 0.05) in Group B. There were no statistical differences between the two groups regarding hemodynamics, pain score, neonatal outcome, and complications. Epidural dexamethasone plus levobupivacaine prolongs the duration of epidural analgesia during management of labor pain with hemodynamic stability and limited maternal and neonatal adverse effects.

Analgesic efficacy and safety of oxycodone as an adjuvant epidural analgesia for patients undergoing laparotomy gynecology

Postoperative pain, when poorly controlled, will cause chronic pain and prolong the healing process. The use of an epidural catheter is a safe and effective method for pain relief in the intraoperative and postoperative period. Opioid as an adjuvant can increase the potency and duration of epidural analgesia. Morphine has been used as an adjuvant in epidural analgesia, but with known side effects such as nausea, vomiting, and pruritus. Oxycodone is one of the opioids which can be given through epidural route as an adjuvant with fewer side effects than morphine. In this case series, we describe six patients with American Society of Anesthesiologists physical status I–II who underwent laparotomy gynecological surgery. All patients were managed by combined general and epidural anesthesia. The regimen for epidural anesthesia is bupivacaine with oxycodone as adjuvant. In this study, we described the hemodynamic profile, quality of analgesia, side effects, and anti-inflammatory effect of oxycodone as an adjuvant in epidural analgesia.

Comparison of Epidural Analgesia Using 0.2% Bupivacaine and 0.2% Ropivacaine for the Management of Postoperative Pain in Major Orthopedic Surgery.

Introduction:Ropivacaine is preferred over racemic bupivacaine for postoperative analgesia as it is less cardiotoxic and has high selectivity for sensory fibers. We aim to compare postoperative epidural analgesia using 0.2% bupivacaine and 0.2% ropivacaine in major lower limb orthopedic surgery.Materials and Methods:In a prospective, randomized, double-blind study, 100 patients, aged 18–70 years, undergoing elective major lower limb orthopedic surgery under spinal anesthesia, were randomly allocated to receive either 7 ml ropivacaine 0.2% (Group R) or 7 ml bupivacaine 0.2% (Group B) for postoperative analgesia through a lumbar epidural catheter. The onset and duration of epidural analgesia, total epidural dose requirement, mean number of epidural topup, rescue analgesia, incidence of motor blockade, and adverse effects were recorded.Results:No differences were noted in demographic data and hemodynamic variables in either group. The onset time of epidural analgesia was 10.46 min ± 0.68 (Group B) and 10.52 min ± 0.71 (Group R). The duration of analgesia was 253.10 ± 17.46 min (Group B) and 251.80 ± 15.77 min (Group R). The total analgesic dose requirement was 78.40 mg ± 6.93 in Group B while in Group R, it was 78.96 mg ± 6.79. Epidural topup requirement and the need for rescue analgesia were similar in both the groups. Motor blockade, hypotension, and nausea were noted more in Group B compared to Group R.Conclusion:In patients undergoing major lower limb orthopedic surgery under subarachnoid block, epidural ropivacaine 0.2% produces effective postoperative analgesia similar to bupivacaine 0.2% with a distinct sensory-motor dissociation resulting in analgesia without motor blockade.

Evaluation of prolonged epidural chloroprocaine for postoperative analgesia in infants

Study ObjectiveTo describe the use and adverse effects of chloroprocaine for epidural analgesia in young infants for infusion durations greater than 3.5 hours. DesignA retrospective cohort review of the electronic medical record over a 14-month period. SettingThe level IV neonatal intensive care unit of a 414-bed free-standing children's hospital. PatientsEighteen infants (mean age, 1.7 ± 1.8 months [0.03-6.3]; mean weight, 3.8 ± 1.3 kg [1.56-6.9]; n = 10 [55%] males) received 1% chloroprocaine for epidural analgesia postoperatively for up to 96-hour duration and met criteria for inclusion. MeasurementsDosing requirements, placement of epidural catheter, supplementary analgesic therapy, respiratory support, vital signs, and incidence of adverse events associated with local anesthetics were collected. Main ResultsEpidural catheter placement was caudal (n = 8), lumbar (n = 6), or thoracic (n = 4). Mean operative time was 2.48 ± 1 hour (1-5). Initial chloroprocaine dose was 1.3 ± 0.5 mL/h (0.4-2.5) (3.5 ± 1 mg/kg per hour [1.4-5]) with a maximum dose of 1.5 ± 0.6 mL/h (0.4-3) (4.2 ± 1.1 mg/kg per hour [2.2-6.1]). Duration of epidural analgesia was 48.3 ± 21.5 hours (10-96). Duration of epidural infusion did not influence dosing requirement, suggesting the absence of drug tachyphylaxis. All patients received intermittent doses of opioid and nonopioid pain medications while receiving chloroprocaine. Two mechanically ventilated patients required continuous infusion of opioids. No adverse events were directly attributed to chloroprocaine use. ConclusionEpidural 1% chloroprocaine, in doses of 0.4-3 mL/h (1.5-6.1 mg/kg per hour), was well tolerated in both mechanically ventilated and spontaneously breathing infants for up to 96 hours with no identified adverse effects or tachyphylaxis.

Comparison of Lidocaine and Lidocaine-Neostigmine for Epidural Analgesia in Water Buffalo Calves (Bubalus Bubalis)

Abstract The object of this study was to evaluate and compare the effectiveness of epidural injection of lidocaine plus neostigmine and lidocaine alone for perineal analgesia in buffalo. Caudal epidural analgesia was performed in six water buffalo calves at the first inter-coccygeal extradural space. It was produced in all calves by 2% lidocaine alone (0.22 mg/kg) and with 2 weeks intervals, repeated by combination of lidocaine–neostigmine (0.22 mg/kg and 10 µg / kg respectively). Analgesia was tested using deep pin prick stimuli. The time of onset and duration of analgesia, ataxia, heart rate, respiratory rate, and rectal temperature were compared among the two treatments. These parameters were determined before drug administration (baseline 0), at 10 minute intervals thereafter. Both treatments resulted in complete analgesia of the tail, perineum, and the upper parts of the hind limbs. The onset of analgesia was faster, but not significant in lidocaine plus neostigmine compared with lidocaine alone (3 ± 1 and 4 ± 1 minute respectively) (mean ± SD) (P > 0.05). The duration of epidural analgesia was significantly longer in lidocaine plus neostigmine than in lidocaine alone (134 ± 11 and 68 ± 9 minutes respectively) (P

936

Introduction: Chloroprocaine is metabolized by plasma cholinesterases and possesses an extremely short half-life. These features make it ideal for infants with immature hepatic function/drug metabolism and may minimize the risk of toxicity. However, only one small study has described intra-operative chloroprocaine during brief surgical episodes (< 3.5 hours) in neonates. Methods: This was an IRB approved, retrospective, electronic medical record review of infants admitted to a children's hospital during a 14-month period who received chloroprocaine for epidural analgesia. Dosing requirements, concomitant analgesia therapy, and possible adverse events related to chloroprocaine were collected. Data are presented as mean ±SD (range) or median when significant skewness was detected. Results: Eighteen patients (age 1.7 ± 1.8 mo (0.03-6.3); weight 3.8 ± 1.3kg (1.56-6.9); 55% male) were enrolled. Surgical classifications included GI (n=13), pulmonary (n=3), ENT (n=1), and orthopedic (n=1). Mean operative time was 2.48 ± 1 hr (1-5). Epidural catheter placement was caudal (n=8), lumbar (n=6), or thoracic (n=4). Epidural analgesia was initiated intra-operatively in 10 patients (55.5%). The remaining infants had their epidural initiated 2.86 ± 2.74 hr (0.76-9.37) post-operatively. Sixty-six percent of epidurals also contained clonidine. The initial dose of chloroprocaine was 3.5 ± 1 mg/kg/hr (1.4-5) with a maximum dose of 4.2 ± 1.1 mg/kg/hr (2.07-6.1). Mean cumulative dose was 177.3 ± 80.6 mg/kg (45-348). Duration of epidural analgesia was 48.3 ± 21.5 hr (10-96). All patients received intermittent doses of opiate and non-opiate pain medications while receiving chloroprocaine, but only two patients (on mechanical ventilation) required continuous infusion opiates. One patient received continuous dexmedetomidine. Median time to extubation post-operatively was 1.56 hrs. No adverse events associated with chloroprocaine use were identified during infusion or within 24 hrs after discontinuation. Conclusions: Epidural chloroprocaine, in doses of 1.5-6.1 mg/kg/hr, can provide adequate analgesia in young infants for up to 96 hrs with no identified adverse effects.

The value of epidural magnesium sulfate as an adjuvant to bupivacaine and fentanyl for labor analgesia

ObjectiveWe conducted this clinical study to assess the adjuvant effects of single dose magnesium sulfate (Mg) when administered epidurally during labor with fentanyl and bupivacaine.MethodsEighty healthy nulliparous women in labor requesting epidural analgesia were divided into two groups. Group 1 received bupivacaine 0.125% with magnesium sulfate 50 mg and fentanyl 50 μg as a loading dose; group 2, received bupivacaine 0.125% and fentanyl 50 μg only. Hemodynamic parameters, motor and sensory evaluation, cervical dilation at time of consenting, the progress of labor, the visual analog pain score (VAS), Apgar score, cord blood acid base status, side effects as nausea, vomiting, itching and respiratory depression were recorded. Fetal heart rate tracings were also documented.ResultsEpidural single dose magnesium sulfate added to bupivacaine and fentanyl in labor resulted in significantly faster onset and longer duration of epidural analgesia (169 ± 50 min) in comparison to those patients who received bupivacaine and fentanyl only (105 ± 41 min), also there was a significant reduction in the number of women requiring additional boluses of bupivacaine when Mg was added (P = 0.016). The two groups had no significant differences as regards maternal satisfaction score, maternal and neonatal adverse effects.ConclusionMagnesium sulfate added to bupivacaine and fentanyl for labor epidural analgesia resulted in faster onset, longer duration of action and reduced the break through pain.

Ambulatory postoperative ward-based epidural analgesia: a retrospective review of 1,147 cases

A retrospective review of 1,147 patients who received epidural analgesia (EA) in surgical wards from January 2008 to December 2009 to determine the prevalence of early ambulation and assess the efficacy and safety of EA for postoperative pain management. Outcome measures were the prevalence of ambulation, pain scores at rest/movement and adverse events. Patients (N = 1,147) who received postoperative EA between January 2008 and December 2009 were included. Motor function was assessed using the Bromage scale. Ambulation was defined as: Day 1: mobilisation from bed to chair, walking on the spot, taking a few steps, thereafter walks of increasing duration and distance at least twice daily. Pain scores were measured using the verbal numerical rating scale (0-10), ≤4 signifying successful analgesia. Daily assessments and data recordings were performed by clinical nurse specialists (CNSs) using standardised charts. Data collected included patient demographics, surgical procedure, ambulation achieved, pain scores at rest/movement and adverse events. The data was analysed using Microsoft Excel(®). The prevalence of ambulation was 88% and this was maintained for the duration of EA. Ninety-eight percent of patients reported pain scores of ≤4 at rest and 88% reported pain scores of ≤4 on movement. Adverse events included motor block 12%, nausea 9%, hypotension 8%, catheter dislodgement 3.8%, leakage from insertion site 1.6%, decubitus ulcers 0.58% and infection 0.001%. Mean duration of EA was 4 days. Ward-based EA facilitates early ambulation, provides excellent postoperative pain relief and is associated with low prevalence of adverse events.

Risk factors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia: a systematic review and meta-analysis of observational trials

BackgroundThis systematic review and meta-analysis evaluates evidence for seven risk factors associated with failed conversion of labor epidural analgesia to cesarean delivery anesthesia. MethodsOnline scientific literature databases were searched using a strategy which identified observational trials, published between January 1979 and May 2011, which evaluated risk factors for failed conversion of epidural analgesia to anesthesia or documented a failure rate resulting in general anesthesia. Results1450 trials were screened, and 13 trials were included for review (n=8628). Three factors increase the risk for failed conversion: an increasing number of clinician-administered boluses during labor (OR=3.2, 95% CI 1.8–5.5), greater urgency for cesarean delivery (OR=40.4, 95% CI 8.8–186), and a non-obstetric anesthesiologist providing care (OR=4.6, 95% CI 1.8–11.5). Insufficient evidence is available to support combined spinal–epidural versus standard epidural techniques, duration of epidural analgesia, cervical dilation at the time of epidural placement, and body mass index or weight as risk factors for failed epidural conversion. ConclusionThe risk of failed conversion of labor epidural analgesia to anesthesia is increased with an increasing number of boluses administered during labor, an enhanced urgency for cesarean delivery, and care being provided by a non-obstetric anesthesiologist. Further high-quality studies are needed to evaluate the many potential risk factors associated with failed conversion of labor epidural analgesia to anesthesia for cesarean delivery.

Uncomplicated Removal of Epidural Catheters in 4365 Patients With International Normalized Ratio Greater Than 1.4 During Initiation of Warfarin Therapy

Current guidelines from the American Society of Regional Anesthesia state that an international normalized ratio (INR) of 1.4 is the upper limit of warfarin anticoagulation for safe removal of an epidural catheter. However, these guidelines are based primarily on expert consensus, and there is controversy regarding this recommendation as being "too conservative." Prospective (3211) and retrospective (1154) patients undergoing total joint replacement followed by daily warfarin thromboprophylaxis were enrolled in this observational study. All nonsteroidal anti-inflammatory drugs and anticoagulants were held before surgery, and all patients had normal coagulation test results before surgery. Patients were followed twice a day by the acute pain service, no other anticoagulants except nonsteroidal anti-inflammatory drugs were administered, and epidural analgesia was discontinued per institutional protocol. Only patients with INR greater than 1.4 at the time of removal of epidural catheter were included. Neurologic checks were performed for 24 hrs after removal. A total of 4365 patients were included, and 79% underwent knee replacement and 18% hip replacement. Mean age was 68 yrs, and mean weight was 81 kg. Mean (SD) duration of epidural analgesia was 2.1 (0.6) days. Mean (SD) INR at the time of epidural removal was 1.9 (0.4), ranging from 1.5 to 7.1. No spinal hematomas were observed (0% incidence with 95% confidence interval, 0%-0.069%). Our series of 4365 patients had uncomplicated removal of epidural catheters despite INRs ranging from 1.5 to 5.9. Removal was only during initiation of warfarin therapy (up to approximately 50 hrs after warfarin intake) when several vitamin K factors are likely to still be adequate for hemostasis.

Operative innovation to the “Nuss” procedure for pectus excavatum: operative and functional effects

Background The “Nuss” procedure for repair of pectus excavatum is performed with increasing frequency worldwide. We describe a technique of performing relaxing or “kerf” incisions along the cartilaginous ribs at the point of maximal chest wall concavity to facilitate retrosternal dissection and to reduce chest wall tension. The effects on operative parameters and long-term changes in cardiopulmonary function and appearance were evaluated prospectively. Methods Thirty patients underwent a Nuss procedure for the period from 2001 to 2004. Fifteen patients underwent a modified Nuss (MN) with sternocostal “relaxing” incisions, and these were compared to 15 patients undergoing a standard Nuss (SN). Data were prospectively gathered and included the number of relaxing incisions, bar number, blood loss, duration of epidural analgesia, number of days to discharge, and preoperative and postoperative cardiopulmonary function measures. Results The average Haller index of the SN group was 3.9 ± 0.7 vs MN group index of 4.6 ± 1.6 ( P < .05). The median number of relaxing incisions in the study group was 4.0 ± 0.7 (range 3 - 8). There were no significant differences between the study groups in any of the operative parameters analyzed, including blood loss, days of epidural requirements or days to reach functional independence. Nor were there differences in the improvement in subjective appearance, complications, pulmonary function, cardiac output at rest, oxygen transport or minute ventilation at maximal exercise. Subjectively, bar positioning and the intraoperative visualization was easier with the relaxing incisions. Conclusions The addition of sternocostal relaxing incisions to the standard Nuss procedure appears to facilitate retrosternal dissection and bar placement, but no changes in long-term function or cosmesis were noted. The use of relaxing incisions appears to be safe and may facilitate operative visualization of retrosternal structures.

Effects on mother and fetus of epidural and combined spinal-epidural techniques for labor analgesia

Epidural (EA) and combined spinal-epidural (CSE) techniques have both been utilized for labor analgesia. This study compared the effects on the mother and newborn of these techniques in labor analgesia and anesthesia. Forty pregnant women received epidural analgesia with 15 mL of 0.125% ropivacaine (EA group) and 5 microg of sufentanil plus 2.5mg bupivacaine in the subarachnoid space (CSE group). Pain intensity, sensory blockade level, latency time, motor block intensity, labor analgesia duration, epidural analgesia duration, maternal hypotension, and pruritus were evaluated. The newborns were evaluated by Apgar and the neurological and adaptive capacity score (NACS) developed by Amiel-Tison. There were no significant statistical differences between groups for pain scores, latency time, sensory blockade level, and Apgar score. Motor block, labor analgesia duration, and epidural analgesia duration were greater in the CSE group, whose seven mothers had mild pruritus. The NACS were greater in the EA group after half, two, and 24 hours. Ninety five percent of EA group newborns and 60% of CSE group newborns were found to be neurologically healthy at the 24 hour examination. EA and CSE analgesia relieved maternal pain during obstetric analgesia, but CSE mothers had pruritus and a longer labor. Newborns of mothers who received epidural analgesia showed the best NACS.

Labor analgesia with ropivacaine added to clonidine: a randomized clinical trial.

Previous studies have led to speculation that the association between ropivacaine and clonidine might be more effective than ropivacaine alone. We examined the maternal-fetal effects of two pharmacological approaches: a low dose of ropivacaine or a lower dose of ropivacaine plus clonidine for epidural analgesia during labor. Prospective study at Department of Anesthesiology, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista. Thirty-two pregnant women in American Society of Anesthesiologists physical status I and II randomly underwent epidural analgesia using 15 ml of ropivacaine 0.125% (R group) or 15 ml of ropivacaine 0.0625% plus 75 microg clonidine (RC group). Pain intensity, sensory block level, latency time, motor block intensity, duration of labor analgesia and duration of epidural analgesia were evaluated. The newborns were evaluated using Apgar scores and the Amiel-Tison method (neurological and adaptive capacity score). There were no statistically significant differences between the groups regarding pain score, sensory block level, duration of epidural analgesia or Apgar score. The latency time, duration of labor analgesia and motor block were R group < RC group. The half-hour and two-hour neurological and adaptive capacity scores were higher in the R group. All of the R group newborns and 75% of the RC group newborns were found to be neurologically healthy at the 24-hour examination. There were no statistically significant differences between the groups regarding pain score, sensory block level, duration of epidural analgesia or Apgar score. The latency time, duration of labor analgesia and motor block were R group < RC group. The half-hour and two-hour neurological and adaptive capacity scores were higher in the R group. All of the R group newborns and 75% of the RC group newborns were found to be neurologically healthy at the 24-hour examination. Both low-dose ropivacaine and a lower dose plus clonidine relieved maternal pain during obstetric labor. Newborns of mothers who received only ropivacaine showed better neurological and adaptive capacity scores.

Demande d'analgésie périmédullaire par les patientes et les équipes obstétricales dans quatre régions françaises. Partie II : réalisation des analgésies périmédullaires

Objective. – Epidural analgesia (EA) is widely used in France to treat the labour pain. The aim of this study was to evaluate and analyse the rate of EA and the ratio between EA required by parturients and total EA realised (performance ratio). Study design. – An epidemiological survey was sent in all maternity units of 4 French areas. Patients and methods. – 48 of the 84 maternity units were participating to the study. In each centre, 25 patients fulfilled the questionnaire and the medical team fulfilled a questionnaire about the organisation of the ward. Rate of EA and performance ratio were calculated. Student t test, χ2 test and logistic regression model were used as requested; p < 0.05 was considered as significant. Results. – The mean rate of epidural analgesia (EA) rate, in the French areas studied, was 61.6%. It was significantly higher in university (79 ± 13.7%) and private hospital (73.1 ± 20.4%) than in general hospitals (54.6 ± 19.6%, p < 0.01), and also in those where anaesthesiologists are dedicated to the maternity unit (71.3 ± 17.8 vs 54.6 ± 22.1%, p < 0.01) and in hospitals where anaesthesiologists were on duty in the hospital versus on call at home (69.8 ± 21.4 vs 56.1 ± 19%, p < 0.02). Median duration of EA was 180 minutes, and 21.3% of them lasted more than five hours. Most of EA was performed between 8 AM and 6 PM. Patients' request was the major reason of EA insertion (OR = 11.81), then the midwife request (OR = 9.01). Other significant factors were the type of the hospital, the anaesthesiologist on duty and parity of women. The ratio between the number of EA requested by parturients and the total number of EA performed was significantly better in university hospitals (100.3 ± 13%) and private hospitals (92.2 ± 15.7%) than in general hospitals (79.4 ± 17.3%, p < 0.02). For the patients who had requested EA and did not have EA, the main reason was that labour was too fast (122/167) and then that there was a fail in anaesthesiologic organization (59/167). The contraindications were rare (14/167). Conclusion. – To correctly answer to the request of EA, it seems necessary that one or more anaesthesiologists were dedicated to the maternity units, and that they were on duty into the hospital. So it seems important to have large maternities with adequate number of anaesthesiologists.

Laparoscopic management for local recurrence of early gastric cancer after endoscopic mucosal resection

Endoscopic mucosal resection (EMR) is a widely accepted technique for early gastric cancer because it is minimally invasive; however, incomplete resection with subsequent cancer recurrence in the remnant remains a difficult problem. Generally, the margins of the local recurrence lesions are unclear, and second EMR is difficult to perform because of scar formation after the first EMR. We performed a laparoscopic treatment on six patients with residual lesions after EMR and reviewed the safety and efficacy of this management. Laparoscopic management consisted of two techniques: laparoscopic wedge resection with a lesion-lifting method and laparoscopic-assisted distal gastrectomy with mini-laparotomy. Cancerous lesions were completely resected with sufficient surgical margins circumferentially. Mean operative time was 171 min, mean estimated blood loss was 16.5 g, time to first walking was 1 day, duration of epidural analgesia was 2.2 days, and mean length of hospital stay was 13.5 days. There were no intra- and postoperative complications, no conversion to open surgery, and no recurrence after surgery. No patients died of gastric cancer during a median follow-up of 60.3 months (range, 38-84). Laparoscopic management for residual lesions of early gastric cancer after EMR is a safe, effective, and minimally invasive procedure by which curative resection can be expected.

Laparoscopic assisted distal gastrectomy for early gastric cancer: Five years' experience

Laparoscopic assisted gastrectomy is being reported increasingly as the treatment of choice for early gastric cancer. However, no reports concerning the prognosis of patients who have undergone laparoscopic assisted distal gastrectomy (LADG) for early gastric cancer or data comparing the results to those obtained after open gastric surgery are yet available. A retrospective study was performed comparing laparoscopic assisted and open distal gastrectomies for early gastric cancer. Eighty-nine patients who underwent LADG were compared to 60 who underwent conventional open distal gastrectomy (DG) in terms of pathologic findings, operative outcome, complications, and survival. There were no significant differences between LADG and DG in operation time (209 vs 200 minutes), complication rate (9% vs 18%), and 5-year survival rate (98% vs 95%). There were differences between LADG and DG with regard to blood loss (237 vs 412 mL), number of lymph nodes (19 vs 25), postoperative stay (17 vs 25 days), and the duration of epidural analgesia (2 vs 4 days) ( P < .05 each). For properly selected patients, LADG can be a curative and minimally invasive treatment for early gastric cancer.