Left Lateral Tilt Research Articles

Exercise echocardiography in hypertrophic cardiomyopathy: reply

We read with great interest the comments by Dimitrow et al. on our paper ‘Comparison of Valsalva manoeuvre and exercise in echocardiographic evaluation of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy’1 and are thankful for their interest in our study. Dimitrow et al. 2–5 have contributed considerably to our understanding of the haemodynamic changes responsible for the development of left ventricular outflow gradient. Dimitrow et al. addressed the question whether or not it is possible to perform exercise treadmill testing in a semi-supine position with a left lateral tilt. This positioning of patients has been used in several studies in our institution,1,6–8 …

Exercise echocardiography in hypertrophic cardiomyopathy

In the paper by Jensen et al. ,1 the authors state that ‘exercise echocardiography was performed as a treadmill test in a semi-supine position and with a left lateral tilt to enable simultaneous transthoracic echocardiography’. Furthermore, the authors wrote that the Bruce protocol was used (it is well known that this protocol is used for treadmill exercise testing). It is our great concern the …

Epidural anaesthesia for caesarian section in a parturient with a single ventricle

Epidural anaesthesia for caesarian section in a parturient with a single ventricle

Chiropractic care of a 6-year–old girl with neck pain; headaches; hand, leg, and foot pain; and other nonmusculoskeletal symptoms

Objective The purpose of this case report is to describe the response to chiropractic care of a pediatric patient with complaints of neck pain; headaches; and hand, leg, and foot pain after head trauma and the reports of changes in the patient's history of chronic fatigue, vomiting, and coughing. Clinical Features A 6-year–old girl was pushed into a playground slide, hitting her head and resulting in acute complaints of her “neck and brain hurting” and hand, foot, and occasional leg pain. In addition, the patient had a several-year history of unexplained fatigue, vomiting, and coughing spells. She had a neck pain disability index of 17.8%; left lateral and rotational head tilt; cervical antalgic lean; loss of cervical range of motion; anterior cervical translation; and spasm, tenderness, trigger points, and edema along the cervical and thoracic spine. Intervention and Outcome The patient was cared for using Activator Methods protocol. After the fifth treatment, all the patient's symptoms dissipated, with a complete return to normal activity and spinal stability after 9 treatments. At 19 weeks, her spine continued to be asymptomatic; and her neck disability index was 0%. Conclusion This case demonstrated that the Activator Method of chiropractic care had a beneficial effect for this pediatric patient.

The hemodynamic effects of a reversed Trendelenburg in elderly patients with increased cardiac risk during laparoscopic cholecystectomy.

We studied the hemodynamic changes induced by pneumoperitoneum and a reversed Trendelenburg in elderly patients with increased cardiac risk (ASA class III; n = 30; age 70.8 +/- 4.9 years, mean +/- SD) and compared the results with elderly patients at normal risk (ASA class II; n = 30; age 69.2 +/- 4.1 years) during laparoscopic cholecystectomy. The transesophageal Doppler monitor was performed after induction of general anesthesia (pre-incision), after onset of pneumoperitoneum (insufflation), after head-up (20degrees) and a left lateral tilt (15degrees) (reversed Trendelenburg) and after deflation and horizontal position (desufflation). Mean arterial pressure (MAP), heart rate, cardiac index (CI) and systemic vascular resistance (SVR) were measured, respectively. Induction of pneumoperitoneum and head-up tilt in patients with cardiac risk resulted significantly in a decrease in CI and an increase in SVR compared with patients with normal risk (P < 0.05), and that remained until deflation, but no interval changes in MAP and heart rate. The CI, MAP and heart rate decreased and SVR increased significantly in patients with cardiac risk compared with patients with normal risk before incision (P < 0.05). No complications occurred. The results indicate that pneumoperitoneum and a reversed Trendelenburg are associated with significant but relatively benign hemodynamic changes. Anesthesia for laparoscopic cholecystectomy in elderly patients with increased cardiac risk should be performed with an adequate hemodynamic monitoring.

Prevention of supine hypotensive syndrome in pregnant women undergoing computed tomography – A national survey of current practice

Aim Supine hypotensive syndrome (SHS) can occur in women in the second half of pregnancy due to compression of the aorta and inferior vena cava by the gravid uterus. This results in a decrease in cardiac output with effects ranging from transient asymptomatic hypotension to cardiovascular collapse. SHS can be easily avoided by left lateral tilt positioning. We undertook a nationwide survey to assess the awareness amongst senior computed tomography (CT) radiographers of the potential risk of SHS in women in this patient group, and to identify the extent to which preventative practices and protocols are in place. Methods and materials A questionnaire was sent to superintendent CT radiographers at all acute NHS Trusts in England and Wales examining awareness of the risk of SHS and the preventative practices and protocols currently used. Results Completed questionnaires were received from 64% institutions. Of respondents who scan women in this patient group, only 44% were aware of the risk of SHS. No institution had a written protocol specifying positioning of women in this patient group. Seventy-five percent of institutions never employed oblique positioning. Eighty-five percent felt that specific guidelines from the Society of Radiographers or Royal College of Radiologists would be helpful. Conclusion Current awareness and practices for preventing this easily avoidable but potentially harmful condition are inadequate. Central guidance would be welcomed by a large majority of respondents.

Does Patient Position Influence Doppler Signal Quality from the USCOM Ultrasonic Cardiac Output Monitor?

The USCOM1A continuous wave cardiac output monitor (USCOM Pty Ltd., Sydney, NSW, Australia) is a novel Doppler-based device used to measure cardiac output noninvasively. The proper alignment of the transducer, and hence the ultrasound beam to the aortic or pulmonary outflow tracts, is essential to acquire accurate measurements and often much time is spent on transducer and/or patient positioning. In this prospective, observational, crossover study, we investigated the effect of patient positioning on the acquisition of cardiac output measurement with USCOM1A. We measured cardiac output using USCOM1A in 30 healthy adult volunteers, each in five different positions: sitting, supine, Trendelenburg (20 degrees), left lateral tilt (20 degrees), and right lateral tilt (20 degrees) and compared the time required to obtain acceptable measurements. We also compared the quality of the Doppler signal obtained in these positions using a scoring system designed for this study. There was a higher rate of failed measurement, the mean time to obtain the first acceptable measurement was prolonged and the optimal measurement obtained within a 5-min period was of a lower quality in the sitting position compared with the other four positions. Our results suggested the sitting position is the least suitable and least reliable position in which to perform cardiac output measurements using USCOM1A compared with the supine, Trendelenburg (20 degrees), left lateral tilt (20 degrees), and right lateral tilt (20 degrees) positions.

Anaesthetic management of Wolff Parkinson White syndrome for caesarean section

We present two cases of WPW syndrome in pregnancy. Risk factors for development of supraventricular tachycardia and the anaesthetic management during caesarean section are discussed. We recommend that regional anaesthesia can be given in patients with WPW syndrome; Phenylephrine is the best vasopressor for treatment of hypotension during spinal blockage and Adenosine is the first line therapy for the acute termination of PSVT. In women of reproductive age, the commonest arrhythmia seen is paroxysmal supraventricular tachycardia (SVT).1 Wolf Parkinson White syndrome accounts for the majority of supraventricular tachycardia in this population; with an incidence of 1.2 per 1000 people. Over half of these patients are asymptomatic.2Patients may complain of palpitation, dizziness, syncope or shortness of breath. The diagnosis is confirmed by E.C.G. The incidence and severity of tachyarrhythmia in these patients may increase during pregnancy. Although reasons for this observation are unclear, some explanations have been proposed. Increased awareness, hemodynamic, hormonal, autonomic and emotional changes related to pregnancy, which may include increase in plasma catecholamine concentrations and adrenergic receptor sensitivity, atrial stretch and increased end diastolic volumes due to intravascular volume expansion have been implicated as some of the reasons.3 We present two cases of Wolf Parkinson White syndrome who underwent caesarean section under regional anaesthesia. A 28 year old female, primigravida, was planned for caesarean section for cephalopelvic disproportion. The patient gave history of palpitations occasionally before pregnancy. But her symptoms increased during pregnancy. The patient did not give any history of syncope, dizziness or chest pain. In preanaesthetic check up, ECG showed features of WPW syndrome. The patient was advised cardiological consultation who confirmed the diagnosis. She was not put on any medication except anxiolytics. She was planned for caesarean section under spinal anaesthesia. Her preoperative heart rate and blood pressure was normal. She was preloaded with 500 ml of normal saline. Routine monitoring included ECG, NIBP and pulse oximetry. Spinal anaesthesia was achieved with 2.5 ml hyperbaric Bupivacaine (12.5 mgs) using 25 G pencil point needle in sitting position. The patient was given a left lateral tilt of 15-20 degrees to prevent supine hypotensive syndrome. A live healthy baby was delivered. Soon after the delivery of the baby, syntocinon 5 units were given as bolus and an infusion of 15 units in 500 ml of normal saline commenced. At this moment patient complained of palpitations and dizziness. Her heart rate increased from 84 to 180 beats / min and her blood pressure dropped to 80 mm Hg. Initially vagal manoeuvres were tried but without any improvement. Injection Phenylephrine 10 μg iv bolus was given which was repeated to treat hypotension. Adenosine 6 mg iv push was given which terminated arrhythmia and sinus rhythm was restored. There were no further episodes of PSVT and post operative period was uneventful. She was discharged after four days and was advised to follow cardiology department. Anaesthetic management of Wolff Parkinson White syndrome for caesarean section

Contribution of the Pelvis to Gesture Leg Range of Motion in a Complex Ballet Movement

Eight skilled ballet dancers performed grand rond de jambe en l'air with the right leg as gesture leg at heights of 90° and 105° as well as their maximal active range of motion (MAR). Three-dimensional motion analysis was performed to quantify the pelvis and gesture-leg motions and to investigate the interaction between pelvic motion and increased leg height. Orientation angles of the pelvis and relative orientation angles of the gesture leg to the pelvis were computed. Events for analysis were defined based on the gesture leg motion, and the pelvis and gesture leg orientation angles at these events as well as the peak values were obtained. One-way repeated-measure ANOVA was used to determine differences among leg heights (p &lt; 0.05). In grand rond de jambe of 90° or higher, dancers gradually increased pelvic motion, especially anterior-posterior and lateral tilts, as the gesture leg height increased. Approximately 4% to 16% of the leg height at end of the ascending motion and 60% of the leg height at initiation of the descending motion were explained by posterior and anterior pelvic tilt, respectively. Maximum left lateral pelvic tilt was equivalent to approximately 45% to 60% of the maximum hip abduction. As the leg height requirement increased, dancers achieved this height primarily by increasing pelvic motion. Gesture leg motion revealed only a minor contribution. In spite of literature in dance pedagogy that suggests that the pelvis should remain immobile during grand rond de jambe, the authors conclude that the pelvis is the primary contributor to the gesture leg range of motion for increased vertical angle demands.

Manual displacement of the uterus during Caesarean section

Ninety ASA 1 and 2 pregnant women with term singleton pregnancies and no maternal and fetal complications, scheduled for elective or emergency Caesarean section, were randomly allocated to group LT (15 degrees left lateral table tilt, n = 45) and group MD (leftward manual displacement, n = 45). Subarachnoid block was established with a 25-gauge spinal needle at the L3-L4 interspace using 1.5 ml of 0.5% hyperbaric bupivacaine. A median sensory level of T6 was observed in both groups but the incidence of hypotension was markedly lower in group MD when compared to group LT (4.4% vs 40%; p < 0.001) with a significant reduction in mean (SD) ephedrine requirement (6 (0) vs 11.3 (4.9) mg; p < 0.001). The mean (SD) fall in systolic blood pressure was 28.8 (7.3) mmHg in group LT and 20 (12.7) mmHg in group MD. The time to maximum fall in systolic blood pressure was similar in both groups (4.5 min). We conclude that manual displacement of the uterus effectively reduces the incidence of hypotension and ephedrine requirements when compared to 15 degrees left lateral table tilt in parturients undergoing Caesarean section.

A Prospective Comparison of Vasopressor Requirement and Hemodynamic Changes During Spinal Anesthesia for Cesarean Delivery in Patients with Multiple Gestation Versus Singleton Pregnancy

It is commonly taught that patients with multiple gestation pregnancy are prone to more severe hypotension during spinal and epidural anesthesia compared to those with singleton pregnancy. However, few quantitative data are available to support this claim. In this study, we prospectively compared vasopressor requirement and hemodynamic changes in patients with multiple gestation versus singleton pregnancy during spinal anesthesia for elective cesarean delivery. Forty parturients with multiple gestation and 60 singleton controls who had identical anesthetic management during spinal anesthesia for elective cesarean delivery were enrolled. After IV prehydration, patients received intrathecal bupivacaine-fentanyl and were tilted to the left. A metaraminol infusion was titrated with the target of maintaining systolic blood pressure at 90%-100% of baseline. Vasopressor dose, minimum and maximum values for systolic blood pressure and the incidences of hypotension, hypertension, and nausea/vomiting were compared. All outcome variables were similar between groups. The total dose of metaraminol required until uterine incision was similar in multiple gestation pregnancy (median 2.9 [interquartile range 2.0-3.7] mg) when compared with singleton pregnancy (median 3.1 [interquartile range 2.3-3.9] mg, P = 0.25; median difference 0.30 mg, 95% confidence interval of difference -0.20 to 0.90 mg). Neonatal outcome was similar between groups. Patients with multiple gestation pregnancy do not exhibit greater hemodynamic instability during spinal anesthesia for cesarean delivery compared to those with singleton pregnancy.

Hasty C-arm Positioning: A Recipe for Disaster

To the Editor: We report here an inadvertent activation of the operating table (Skyton 3100; John Cudia & Associates, Morgan Hill, CA) tilt by a C-arm operated by a surgeon. An anesthetized and paralyzed patient was placed in the left lateral position for a neurosurgical procedure. Before the patient could be appropriately secured, the surgeon moved the C-arm into position over the operating room table. Unbeknownst to all concerned, the bottom end of the C-arm (i.e., the part of the C arm closest to the floor) wedged onto the floor control of the Skyton operating table. This resulted in the continuous activation of the table into a full left lateral tilt. The patient was prevented from falling from the table by nursing staff and a surgical resident who held him with outstretched arms. With the table tilting uncontrollably for no apparent reason, the operating room table was unplugged. This stopped the movement but the patient was still at a 30°-40° tilt. However, the base of the C-arm was now seen on top of the Skytron floor control. The C-arm was removed and the operating room table was again plugged into the electrical outlet. The operating room table control was now able to function correctly and the patient was uneventfully tilted back into a supine position using the control. We bring this case to the attention of your readership as a potential disaster that can occur when floor controls are in close proximity to a maneuvering C-arm. John G. Brock-Utne, MD, PhD Patrick Bolton, MD Gina Marie Zisook, RN Stanford University Medical Center, Stanford, CA, [email protected]

Acute Torticollis After Isolated Stress Fracture of the First Rib in a Child: A Case Report

I solated stress fractures of the first rib have previously been reported in adults and adolescents who participate in sports such as rugby1, baseball2, weight-lifting3, basketball4, and tennis5 as well as in individuals who carry a heavy schoolbag6. Stress fractures of the first rib in children are rare, and only five fractures in four patients have been reported (Table I)1,7-9. The clinical presentation usually ranges from mild vague discomfort to acute pain in the shoulder region, cervical triangle, or clavicular region. Pain also may radiate to the sternum or the pectoral region. No cases of painful torticollis due to a stress fracture of the first rib in a child have been reported, to our knowledge. Common causes of acquired painful torticollis are trauma (atlantoaxial rotatory displacement10, os odontoideum11, and C1 fracture12), inflammation13 (Grisel syndrome14, juvenile rheumatoid arthritis15, discitis15), and tumor (eosinophilic granuloma16, osteoid osteoma17, osteoblastoma18, leukemia19). Less common causes include calcified cervical disc20, Sandifer syndrome21, and bacterial meningitis22. View this table: TABLE I Previous Cases of Stress Fractures of the First Rib in Children The present report emphasizes that the diagnosis of isolated stress fracture of the first rib should also be considered when a child presents with an acute painful torticollis. The patient was informed that data concerning this case would be submitted for publication. Fig. 1-A Initial anteroposterior radiograph of the cervical spine, demonstrating left lateral cervical tilt. A faint fracture line of the left first rib (arrow) was missed on the initial reading but was visible on secondary review. A n eight-year-old, right-hand-dominant boy was evaluated in our department for acute torticollis. …

Remarks on guidelines ERC 2000: cardiac arrest associated with pregnancy

We would like to make some comments about managing cardiopulmonary arrest in pregnant women as it is described in the guidelines of Resuscitation 2000;46:293–5 [[1]Special issue. International Guidelines 2000 for CPR and ECC—A Consensus on Science. Resuscitation 2000;46:293–5.Google Scholar]. The International 2000 guideline states that it is not advisable to resuscitate a pregnant woman lying on her back because the gravid uterus may obstruct venous return via the inferior vena cava and therefore chest compression is more less likely to be effective. Indeed, studies confirm that applying a partial left lateral tilt to the patient will relieve the aorto-caval compression [[2]Johnson MD, et al. Cardiopulmonary resuscitation. In: Gambling DR, Douglas MJ, editors. Obstetric anaesthesia and uncommon disorders. Philadelphia: WB Saunders; 1998. p. 51–74.Google Scholar]. Rees and Willis [[3]Rees G.A.D Willis B.A Resuscitation in late pregnancy.Anaesthesia. 1988; 43: 347-349Crossref PubMed Scopus (127) Google Scholar] conclude that the best compromise for cardiopulmonary resuscitation (CPR) is achieved by wedging the patient at an angle of 27°. However at this angle there is a disadvantage in that the rescuer can provide only 80% of the transmitted external resuscitative force. Because the transmission forces during external CPR in this position are not perpendicular to the thorax and a part of the transmitted force is lost, left lateral positioning for CPR is not ideal. Overturned chairs and positioning the patient in the full lateral position as shown in Fig. 1, page 294 of the International resuscitation guidelines 2000 [[1]Special issue. International Guidelines 2000 for CPR and ECC—A Consensus on Science. Resuscitation 2000;46:293–5.Google Scholar] make external CPR impossible [[3]Rees G.A.D Willis B.A Resuscitation in late pregnancy.Anaesthesia. 1988; 43: 347-349Crossref PubMed Scopus (127) Google Scholar]. Because chest compression are more effective in the supine position than in the left lateral wedge position, the best compromise for CPR and optimal venous return is in the supine position with manual displacement of the uterus to the left as recommended by Johnson et al. [[2]Johnson MD, et al. Cardiopulmonary resuscitation. In: Gambling DR, Douglas MJ, editors. Obstetric anaesthesia and uncommon disorders. Philadelphia: WB Saunders; 1998. p. 51–74.Google Scholar]. The guidelines indicate no changes to the standard algorithms for medication, intubation and defibrillation. However intubation is more difficult and defibrillation is different compared to the non-pregnant cardiac-arrest situation. As pregnant women present dextroversion of the heart, one paddle should be placed below the right clavicle in the midclavicular line while the second paddle should be placed outside the normal cardiac apex avoiding breast tissue [[4]Luppi C.J Cardiopulmonary resuscitation: pregnant women are different.AACN Clin Issues. 1997; 8: 574-585Crossref PubMed Scopus (18) Google Scholar]. Also, the timing of emergency caesarean section is open to criticism. Understandably, the discussion is not easy. In the International Guidelines 2000 on pages 294 and 295 [[1]Special issue. International Guidelines 2000 for CPR and ECC—A Consensus on Science. Resuscitation 2000;46:293–5.Google Scholar] it is recommended to attempt basic life support (BLS) first and only to proceed with emergency caesarean section if advanced measures have been commenced already and the problems are not immediately reversible. But hesitation punishes the pregnant patient and guidelines do not give clear guidance when emergency caesarean section should be started during the algorithm. The guideline on page 294 suggests that after BLS and advanced life support (ALS) have failed, and if there is some chance that the fetus is viable, immediate perimortem caesarean section has to be considered. This can be confusing for medical personnel unfamiliar with the difficulties of parturient cardiac arrest. Even if the fetus is not viable emergency cesarean section is required in order to improve venous return and consequently the cardiac output during CPR. Following delivery of the fetus cardiac output in non cardiac arrest patients can increase up to 80% above predelivery values [[5]Ueland K Hansen J.M Maternal cardiovascular dynamics 3. Labor and delivery under local and caudal analgesia.Am. J. Obstet. Gynecol. 1969; 103: 8-18Abstract Full Text PDF PubMed Scopus (138) Google Scholar]. Because maternal brain damage is likely after 4 min of sustained cardiac arrest [6American Heart Association. Textbook of advanced cardiac life support. Dallas: AHA; 1987.Google Scholar, 7Archer G.W Marx G.F Arterial oxygen tension during apnoea in parturient women.Br. J. Anaesth. 1974; 46: 358-360Crossref PubMed Scopus (122) Google Scholar] and may be irreversible after 6 min [[8]Weber C.E Postmortem cesarean section: review of the literature and case reports.Am. J. Obstet. Gynecol. 1971; 110: 158-165PubMed Scopus (49) Google Scholar] perimortem cesarean section should be considered at the fourth minute of cardiac arrest. It should be mentioned that, after perimortem delivery, 10 units of oxytocin should be injected in the myometrium to prevent uterine bleeding. Also, if external chest compressions are unsuccessful after 15 min open cardiac message should be considered (Johnson et al. 1998).

Acute airway obstruction during spinal anaesthesia for caesarean section

A 30-year-old primiparous Caucasian woman with known placenta praevia required an emergency caesarean section for a mild antepartum haemorrhage at the onset of spontaneous term labour. Following intravenous prehydration with 500 ml gelatin colloid (Haemaccel™), spinal anaesthesia was induced in the sitting position with 2.6 ml of 0.5% hyperbaric bupivacaine (13 mg). The patient was then placed in the recumbent position with left lateral tilt, whereupon she suddenly became dyspnoeic. A generalized erythematous urticarial rash with associated facial, periorbital, glossal and perioral oedema became evident. Although maternal blood pressure remained within normal limits, emergency conversion to general anaesthesia with tracheal intubation was necessary to secure the airway. Laryngoscopy revealed gross submucosal, epiglottic and pharyngeal oedema, characteristics of the syndrome of angioneurotic oedema, which may complicate an anaphylactoid reaction. After the airway was secured with a cuffed endotracheal tube, caesarean section proceeded uneventfully and a healthy male infant was delivered. Maternal facial and airway oedema subsided and extubation was performed in intensive care 2 h later. Life-threatening airway obstruction often accompanies angioneurotic oedema. Since parturients have a higher incidence of difficult airway management than the general population, anaphylactoid reactions presenting as angioneurotic oedema pose a particular challenge for the anaesthetist. The lower incidence of allergy associated with hydroxyethyl starch (Hetastarch) may make it a more appropriate choice of colloid in this setting. However, the balance of evidence now suggests that vasopressors, particularly ephedrine, are superior to fluids for maintenance of blood pressure during regional anaesthesia for caesarean section.

Weight gain during pregnancy does not influence the spread of spinal analgesia in the term parturient.

It is still controversial whether the spread of spinal anaesthesia in pregnancy is influenced by particular physique. Investigation was based on a clinical observation that parturients with a pronounced "pregnant" physique, e.g. generalised oedema and heavy abdomen, tended to develop more cephalad sensory blockades than parturients without these physical signs. Using weight gain during pregnancy as a measure for the physique at term, we aimed to determine whether this parameter influences the distribution of analgesia after subarachnoidal injection of plain bupivacaine. Thirty women presenting for elective Caesarean section were studied. All the women received 13.5 mg plain bupivacaine via subarachnoid injection at the L2-3 interspace. Thirty minutes after the injection, while the women were in the supine position with a left lateral tilt on a horizontal operating table, the maximum cephalad extent of sensory analgesia (loss of sensation to sharpness of pinprick) was determined. Neither weight gain during pregnancy (6-22 kg, range), height (152-185 cm), weight (56-98 kg) nor body-mass index (20.2-31.8 kg/m2) correlated with the cephalad spread of sensory blockade. In parturients, weight gain during pregnancy, height, weight and body-mass index did not influence the extent of sensory analgesia after subarachnoidal administration of plain bupivacaine.

Changes in tracheal tube position during laparoscopic cholecystectomy.

The distance from the carina to the tip of the tracheal tube was measured with a fibreoptic bronchoscope in 21 consecutive patients undergoing elective laparoscopic cholecystectomy. After placement of an Eschmann tracheal tube with a printed intubation guide mark at the vocal cords, the distance was 28 (15) [5-54] mm (mean (SD) [range]). The tube was then repositioned so that the distance was 34 (3) [30-40] mm from tip of the tube to the carina. After creation of pneumoperitoneum, the distance was significantly decreased to 26 (5) [17-35] mm (p < 0.005), which was not significantly altered by subsequent moving of the patient to the reverse Trendelenburg and left lateral tilt position. The maximum distance of tube migration was 8 (4) [0-15] mm. Four out of 21 patients would have been at risk of bronchial intubation after pneumoperitoneum if the tube had not been repositioned. Placement of the tube according to the guide mark is not recommended for laparoscopic cholecystectomy.

Spinal anaesthesia for Caesarean section: effect of Sprotte needle orientation

We induced spinal anaesthesia in 100 women presenting for elective Caesarean section with the mother in the right lateral position. Patients were allocated randomly to have the side eye of the 24-gauge Sprotte spinal needle pointing in one of four directions: group A, cephalad; group B, right lateral; group C, left lateral; group D, caudad. Isobaric bupivacaine 0.5% (2.5 ml) was injected over 30 s before the mother was placed supine with a 15 degree left lateral tilt. Onset time and height of the subsequent analgesic and anaesthetic blocks were assessed by a blinded observer. Onset of sensory block to T4 was significantly faster in group A (P = 0.001). There were no differences in final block height, incidence of hypotension, nausea and vomiting or ephedrine requirements.

Uteroplacental haemodynamics during spinal anaesthesia for caesarean section with two types of uterine displacement

The effects of two types of uterine displacement, on uterine and umbilical artery blood flow waveforms were investigated in 22 healthy parturients undergoing elective caesarean section. Displacement was accomplished with either a wedge under the right hip or a mechanical displacer plus 5° left lateral tilt of the operating table. The first 14 patients were assigned randomly into one of the two displacement methods and the left (underlying) uterine and umbilical artery blood flow waveforms were recorded. In a further 8 patients the displacer was used and flow velocity waveforms for both the right and left uterine arteries and the umbilical artery were recorded. Arterial resistance was expressed in terms of the pulsatility index (PI). There were no significant changes in Doppler velocimetry recordings after preloading in either group, but blood flow velocity waveform indices for the underlying left uterine artery increased significantly ( P < 0.001) following spinal anaesthesia when the mechanical device was used. This finding indicates increased vascular resistance in the left uterine artery and is probably due to mechanical compression. A wedge as a method for displacing the gravid uterus seems preferable since its use had no effect on the blood flow indices. The unaltered umbilical artery index values in the groups suggest a great tolerance of minor changes in maternal uterine circulation on the part of the fetus.

Does posture have an effect on neonatal outcome during the conduction of spinal anaesthesia?

Around 10% of pregnant women develop supine hypotension syndrome. In others, supine compression of the inferior veva cava is concealed since there is no change in maternal blood pressure and only a small decrease in cardiac output.’ To avoid the problems of supine hypotension, the lateral position has been advocated for maternal management during labour for fetal blood sampling and even for establishing regional anaesthesia. As a result it has become increasingly popular to perform regional anaesthesia for caesarean section (CS) in the lateral position and to maintain the lateral position until surgery is ready to begin. However, no prospective randomised studies have been undertaken to compare the effect of lateral position with left lateral tilt position on neonatal outcome. The aim of this study was to assess whether there was a difference in neonatal outcome if parturients were placed in left lateral or 20” left lateral tilt position after the induction of spinal anaesthesia.