Rescue Boluses Research Articles

Sedation and analgesia in the trauma intensive care unit of Inkosi Albert Luthuli Central Hospital - the effect of anti-retroviral therapy: A retrospective chart analysis.

Adequate access to antiretrovirals (ARV) has improved the longevity and quality of life of people living with the human immunodeficiency virus(HIV). Antiretrovirals are known to cause multiple drug-drug interactions. It was noted clinically that patients on ARVs appeared to be more difficult to sedate. This begs the question of the clinical impact of these drug interactions, should clinicians adjust sedative dosages when managing patients on ARVs? This study aimed to investigate the presence of and measure the differences in sedation and analgesic utilisation between polytrauma patients on ARVs and those not on ARVs. This retrospective observational chart review included consecutive adult polytrauma patients admitted to the Trauma ICU IALCH between January 2016 and December 2019. HIV status and ARV use was documented. The total sedation per drug utilised at 24, 48 and 72-hour interval was calculated and tabulated accordingly. Drug utilisation was compared to ARV status. A total of 216 adult polytrauma patients were included in the study. A total of 44 patients were HIV positive and 172 were HIV negative. Of the HIV positive patients 41 (93.2%) were on ARVs. Multiple comparisons were confirmed, however the primary analysis compared HIV negative patients with HIV positive patients on ARV. Total morphine, ketamine, midazolam and propofol doses were all numerically greater in patients on ARVs, although none of these reached statistical significance. The use of morphine rescue boluses during the first 72h of ICU admission and the doses of ketamine and propofol on ICU day 3 were significantly greater in those on ARVs. The data analysis showed that patients on ARVs required higher doses of some analgesia and sedation in ICU and lower doses of midazolam. This needs to be considered when sedating patients in a setting with a high HIV prevalence.

Programmed Intermittent Epidural Boluses of 0.1% Ropivacaine Versus 0.2% Ropivacaine for the Maintenance of Epidural Analgesia in Labor.

Objective The gold standard for pain management during labor is epidural analgesia, which can be administered in two different ways to the parturients, either bybolus doses or continuous infusions of local anesthetic solutions with opioids. Recently, programmed intermittent epidural boluses (PIEBs) via a pump are gaining popularity as a very effective method with minimal side effects. The aim of this study was to evaluate the optimum ropivacaine concentration between two different regimens (0.1% or 0.2% both with fentanyl 2 μg/ml) that can provide satisfactory analgesia with the minimum degree of motor blockade, using PIEBs. Methods A prospective randomized controlled study was performed from March 2020 to March 2022. Two different concentrations of ropivacaine 0.1% and 0.2% via PIEBs were equally allocated to two groups of parturients with an additional patient control epidural rescue bolus if needed. Our primary endpoint was motor blockade, as assessed by the modified Bromage scale (MBS). We also recorded visual analog scale (VAS) scores, heart rate, blood pressure, total local anesthetic consumption, labor duration and method of delivery, and APGAR score of the newborns. Results All patients presented Bromage scores equal to 6, and the total consumption of the anesthetic solution was comparable between the two groups. Women in the 0.2% group showed higher pain relief and satisfaction compared to the 0.1% group. Concerning the 0,2% group, diastolic blood pressure and APGAR scores were lower alongside with a lower satisfactory extrusion stage observed bythe obstetrician. Conclusion Both ropivacaine regimens provide satisfactory labor epidural analgesia for the expectant mother without any motor blockade.

Comparison of Prophylactic Phenylephrine Infusion and Rescue Bolus Administration for Maintaining Blood Pressure During Spinal Anaesthesia for Caesarean Delivery in Obese Parturient: A Randomised Control Trial.

Phenylephrine (PE) is one of the vasopressor used to treat hypotension during anaesthesia. The primary aim of this study was to compare the effect of prophylactic infusion and rescue bolus of PE on the haemodynamic changes during spinal anaesthesia (SA) for Caesarean section (CS) in obese parturients. A total of 74 obese parturients scheduled for elective CS under SA were randomised into two groups; Group A (n = 37) received prophylactic PE infusion starting at 50 μg min-1 and adjusted according to the given algorithm and Group B (n = 37) received 100 μg PE bolus to treat hypotension. The measured parameters were systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), the total requirement of PE and neonatal Apgar score. Six patients were excluded from the analysis due to missing data and only 68 were analysed. Group A showed significantly higher SBP, DBP and MAP than Group B (P < 0.05). The requirement of PE was higher in Group A than Group B [817.7 (265.7) μg versus 360.6 (156.0) μg; P = < 0.05]. Both groups had no difference in terms of the neonatal Apgar score. Prophylactic PE infusion provided better haemodynamic control than therapeutic boluses in obese parturients undergoing CS under SA.

Use of vasopressors to manage spinal anesthesia-induced hypotension during cesarean delivery.

Cesarean sections are commonly performed under spinal anesthesia, which can lead to hypotension, adversely affecting maternal and fetal outcomes. Hypotension following spinal anesthesia is generally defined as a blood pressure of 80-90% below the baseline value. Various strategies have been implemented to reduce the incidence of spinal anesthesia-induced hypotension. The administration of vasopressors is a crucial method for preventing and treating hypotension. In the past decade, phenylephrine, a primarily alpha-adrenergic agonist, has been the preferred vasopressor for cesarean sections. Recently, norepinephrine, a potent alpha-agonist with modest beta-agonist activity, has gained popularity owing to its advantages over phenylephrine. Vasopressors can be administered via a bolus or continuous infusion. Although administering boluses alone is simpler in a clinical setting, continuous prophylactic infusion initiated immediately after spinal anesthesia is more effective in reducing the incidence of hypotension. Tailoring the infusion dose based on the patient's body weight and adjusting the rate in response to blood pressure changes, in addition to using a prophylactic or rescue bolus, helps reduce blood pressure variability during cesarean sections under spinal anesthesia until neonatal delivery.

Comparison of efficacy and safety of three different concentrations of ropivacaine for labor pain management using patient-controlled epidural analgesia (PCEA): A double-blind, randomized controlled trial.

Labor pain is consistently ranked high on the various pain rating scales, when compared to other painful life experiences, and the experience of labor during the process of childbirth is both complex and subjective. Though patient-controlled epidural analgesia (PCEA) using dilute concentrations of local anesthetics (LAs) has been a popular method to control labor pain, yet the optimal dose and regimen for PCEA remain ambiguous. So, the present study was undertaken to evaluate the safety and efficacy of three different concentrations of ropivacaine for labor analgesia using PCEA. Seventy-five healthy nulliparous women who gave voluntary consent for labor analgesia using PCEA were randomly assigned to three groups to receive three different ropivacaine concentrations (0.0625%, 0.1%, and 0.125%) with adjuvant fentanyl 2 μg/ml, after double-blinding. Analgesic efficacy, neuraxial blockade, vital parameters, neonatal outcomes, maternal satisfaction, and side effects were assessed. Primary outcome was total dose of ropivacaine consumed in milligrams. Number of pain breakthroughs (Visual Analog Score >4) and PCEA demand and rescue boluses were found to be statistically more in group 0.0625% (P < 0.01), followed by group 0.1% and were the least in 0.125%. Still, total drug consumed in milligrams was significantly less in 0.0625% group. Maternal satisfaction was comparable among the three groups (P = 0.33). There was no significant difference in maternal side effects and neonatal APGAR scores among the three groups. When three different concentrations of ropivacaine, that is, 0.0625%, 0.1%, and 0.125%, are used for labor analgesia, the use of 0.125% ropivacaine leads to higher total amount of ropivacaine consumed. Despite the lower efficacy in terms of breakthrough pain episodes observed with a 0.0625% ropivacaine concentration for labor analgesia, maternal satisfaction remained consistent across all three doses of ropivacaine. PCEA demand and rescue boluses for the lowest concentration, that is, 0.0625%; and did not affect maternal satisfaction with the management of labor pain.

Dexmedetomidine as an Adjunct to Propofol in Patients Undergoing Elective Endoscopic Retrograde Cholangio-Pancreaticography - A Double-blind Randomized Controlled Study.

Propofol is the drug of choice for procedural sedation. The addition of α2 agonist dexmedetomidine may improve the safety profile of the procedure by providing stable hemodynamics, better sedation quality, and decreasing the side effects of each drug during elective endoscopic retrograde cholangio-pancreaticography (ERCP). Eighty patients aged between 18 and 60 years were distributed randomly into two groups. The dexmedetomidine + propofol group (group DP) received an injection of dexmedetomidine at the dose of 1 mcg/kg in 100 mLsaline, and the propofol group (group P) received plain 100 mL normal saline over 10 min. Subsequently, both groups received a bolus dose of injection propofol 1 mg/kg as sedation, and a modified observer's assessment of alertness/sedation score (MOASS) score was assessed, followed by infusion at the rate of 50 mcg/kg/min during the procedure. A rescue bolus dose (20 mg) of propofol was administered when the patient showed signs of inadequate sedation or analgesia in both groups. Cardiovascular and respiratory parameters were recorded every 10 min throughout the procedure. Post-procedure modified Aldrete score was evaluated for 30 min, and the endoscopist's score was noted at the end of the procedure. There was a significant difference (P = 0.001) in the additional number of rescue doses of propofol administered in group DP (3.47 ± 0.77) as compared to group P (8.78 ± 1.11). The total dose of propofol was lower in group DP (316.59 ± 43.29 mg) than in group P (443 ± 41.1 mg) with P value = 0.001. Statistically significant differences in the hemodynamic values were observed in group DP during infusion (P value < 0.05) of dexmedetomidine and throughout the procedure (P < 0.05) when compared with group P. Endoscopists graded the satisfaction score as very high (3.477 ± 0.77) in group DP. The addition of dexmedetomidine to propofol during ERCP provided better and safer sedation.

Post-spinal hypotension management for cesarean section in low resource settings: efficiency and safety of two very low-dose boluses of norepinephrine, a randomized double-blinded controlled trial

Spinal anesthesia is the gold standard anesthetic technique for cesarean section. However, its major complication is hypotension. Norepinephrine has recently been described as an efficient and safe alternative to Phenylephrine. The aim of this study was to determine the effective target bolus of Norepinephrine to prevent and treat post-spinal anesthesia hypotension. We conducted a prospective controlled randomized study including 126 parturients scheduled for cesarean delivery under spinal anesthesia. We compared two groups that received a prophylactic bolus of either 1μg/kg or 0.5μg/kg of Norepinephrine without fluid loading. The rescue intravenous bolus of Norepinephrine was half the dose of the prophylactic bolus. The main outcomes were the percentage of decrease in systolic and mean blood pressure. The secondary outcomes included the timing of the first hypotension, duration of hypotension, number of rescue boluses, total Norepinephrine consumption, incidence of hypotension and maternal adverse effects and fetal outcomes. Our primary outcome has shown similarities between groups; delta systolic blood pressure before delivery was 19.4% in group 1µg/kg versus 20.5% in group 0.5µg/kg. Both groups were similar for all secondary outcomes, except that the higher dose of Norepinephrine resulted in more hypertension. Fetal outcomes were similar in both groups. Bolus of 0.5μg/kg followed by rescue doses of 0.25μg/kg of Norepinephrine was efficient in preventing and treating spinal anesthesia-induced hypotension. These doses may be recommended for routine use in healthy parturients.

A randomized comparative study of patient-controlled epidural analgesia with manual standard intermittent bolus for labor analgesia

Background: Patient-controlled epidural analgesia (PCEA) pump has proven to reduce the incidence of unscheduled clinician interventions and total dose of local anesthetic administered for labor pain. Aims and Objectives: The aim of the study was to compare the quality of analgesia, maternal satisfaction, amount of rescue analgesia needed, and neonatal outcome between clinician delivered manual bolus doses and PCEA pumps for epidural labor analgesia. Materials and Methods: 60 parturients of the American Society of Anesthesiologists II scheduled for normal vaginal delivery were randomly divided into two groups, Group A (PCEA) and Group B (Manual bolus). Both groups received an initial epidural bolus of 10 mL of 0.125% Inj. Bupivacaine+20 mcg injection fentanyl. Group A (PCEA) patients received a basal infusion of 5 mL/h with self-administered bolus of 2 mL with a lockout interval of 15 min. Group B patients were provided with a bolus of 10 mL of the same solution manually after every hour. Patients of both groups were given manual rescue boluses for distressing pain (visual analog scale [VAS] &gt;5). Results: Mean VAS score in Group A was 2.97±0.73; and in Group B, it was 3.03±0.56 (P&gt;0.05). Total bupivacaine use and mean duration of second stage of labor in both groups was found comparable. Mean top-up requirement of local anesthetics was significantly high in Group B. Maternal satisfaction was also higher in PCEA group. Conclusion: As PCEA pump provides continuous infusion of local anesthetics, there was lesser requirement of top ups of bupivacaine and higher maternal satisfaction score in PCEA group than manual bolus group.

Assessing Continuous Epidural Infusion and Programmed Intermittent Epidural Bolus for Their Effectiveness in Providing Labor Analgesia: A Mono-Centric Retrospective Comparative Study.

Background and Objectives: Local anesthetics administered via epidural catheters have evolved from intermittent top-ups to simultaneous administration of continuous epidural infusion (CEI) and patient-controlled epidural analgesia (PCEA) using the same device. The latest programmed intermittent epidural bolus (PIEB) model is believed to create a wider and more even distribution of analgesia inside the epidural space. The switch from CEI + PCEA to PIEB + PCEA in our department began in 2018; however, we received conflicting feedback regarding workload from the quality assurance team. This study aimed to investigate the benefits and drawbacks of this conversion, including the differences in acute pain service (APS) staff workload, maternal satisfaction, side effects, and complications before and after the changeover. Materials and Methods: Items from the APS records included total delivery time, average local anesthetic dosage, and the formerly mentioned items. The incidence of side effects, the association between the duration of delivery and total dosage, and hourly medication usage in the time subgroups of the CEI and PIEB groups were compared. The staff workload incurred from rescue bolus injection, catheter adjustment, and dosage adjustment was also analyzed. Results: The final analysis included 214 and 272 cases of CEI + PCEA and PIEB + PCEA for labor analgesia, respectively. The total amount of medication and average hourly dosage were significantly lower in the PIEB + PCEA group. The incidences of dosage change, manual bolus, extra visits per patient, and lidocaine use for rescue bolus were greater in the PIEB + PCEA group, indicating an increased staff workload. However, the two groups did not differ in CS rates, labor time, maternal satisfaction, and side effects. Conclusions: This study revealed that while PIEB + PCEA maintained the advantage of decreasing total drug doses, it inadvertently increased the staff burden. Increased workload might be a consideration in clinical settings when choosing between different methods of PCEA.

Low-cost, low-power, clockwork syringe pump

A low-cost ($120 NZD, $75 USD), low-power (1-year battery life), portable, and programmable syringe pump design is presented, which offers an alternative to high-cost commercial devices with limited battery life. Contrary to typical motor-driven syringe pumps, the design utilizes a compression spring coupled with a clockwork escapement mechanism to advance the syringe plunger. Full control over flow-rate and discrete (bolus) deliveries is achieved through actuation of a clockwork escapement using programmable, low-power electronics. The escapement mechanism allows the syringe plunger to advance a fixed linear distance, delivering a dose size of 0.001ml in the configuration presented. The modular pump assembly is easily reconfigured for different applications by interchanging components to alter the minimum dose size. Testing to IEC 60601-2-24(2012), the average error of the clockwork syringe pump was 8.0%, 4.0%, and 1.9% for 0.001ml, 0.002ml, and 0.01ml volumes, respectively. An overall mean error of 1.0% was recorded for a flow-rate of 0.01mlh−1. Compared to a commercial insulin pump, the clockwork pump demonstrated reduced variability but greater average error due to consistent over-delivery. Further development of the design and/or manufacture should yield a device with similar performance to a commercial pump.

Effect of programmed intermittent epidural bolus protocol on physician-administered rescue boluses of labor analgesia

Background Prior studies have shown that programmed intermittent epidural bolus (PIEB) techniques, with or without patient-controlled epidural analgesia (PCEA) boluses, provide better pain relief, reduced motor block, and better patient satisfaction compared to continuous epidural infusion (CEI) techniques. We hypothesized that patients who had labor epidural analgesia (LEA) maintained with PIEB and PCEA would be less likely to receive a physician-administered rescue analgesia bolus compared to patients who had CEI and PCEA. Methods We searched our electronic medical record for patients who had CEI and PCEA from August 1, 2021 to December 31, 2021 and for patients who had PIEB and PCEA from August 2, 2022 to December 31, 2022. Results A total of 792 and 665 patients had maintenance of LEA with CEI/PCEA and PIEB/PCEA, respectively. A multivariate logistic regression was performed and, after adjusting for variables of interest, patients who had PIEB and PCEA were less likely to receive one or more physician-administered rescue analgesia boluses (odds ratio 0.504; 95% confidence interval 0.392, 0.649; P < 0.001) compared to patients who had CEI and PCEA. Conclusion PIEB/PCEA was associated with fewer physician-administered boluses of rescue analgesia compared to CEI/PCEA when used for LEA.

Prophylactic Fixed-Rate Phenylephrine Versus Norepinephrine Infusion in the Prevention of Post-spinal Anesthesia Hypotension During Cesarean Delivery.

Background Maternal hypotension following spinal anesthesia can be actively countered by the use of vasopressors. Prophylactic infusion of vasopressors with a rescue bolus dosing was observed to be more effective for hemodynamic stability when compared to administering a bolus dose alone. Although phenylephrine is the recommended drug to treat spinal hypotension, many recent studies have focussed on the role of norepinephrine infusions during cesarean section. In this study, we compared prophylactic fixed-rate intravenous infusions of phenylephrine and norepinephrine during cesarean delivery under spinal anesthesia and the requirement of intraoperative provider-administered rescue bolus of phenylephrine needed to overcome post-spinal anesthesia hypotension. Methodology A total of 208 patients undergoing elective cesarean section under spinal anesthesia were randomly assigned to two groups (group P and group N). Group N included 104 patients who received norepinephrine infusion at a rate of 2.5 μg/minute (0.04 μg/kg/minute), and group P included 104 patients who received phenylephrine infusion at a rate of 50 μg/minute (0.8 μg/kg/minute)to treat spinal hypotension. The primary outcome of our study was to compare the reduction in the number and total dose of intraoperative provider-administered rescue bolus of phenylephrine needed to maintain systolic blood pressure. The secondary outcome of our study was to compare the neonatal outcome using umbilical venous blood gas sampling and Apgar score at one and five minutes. Results The total number of phenylephrine rescue bolus required to treat hypotension was significantly lower in group N (p = 0.0005) compared to group P. The neonatal outcome was similar between the two groups. Conclusions Prophylactic norepinephrine infusion when compared to prophylactic phenylephrine infusion is associated with a lesser requirement of rescue phenylephrine boluses.

Intravenous Dexmedetomidine-Ketamine Versus Ketamine-Propofol for Procedural Sedation in Adults Undergoing Short Surgical Procedures: A Randomized Controlled Trial.

Background and objective Moderate to deep sedation is a prerequisite during total intravenous anesthesia for short-duration surgeries, and it can be achieved by using individual drugs or in combination. Our study compared dexmedetomidine-ketamine (DK) versus ketamine-propofol (KP) in terms of sedation, procedural interference, hemodynamics, and incidence of side effects in patients undergoing short surgical procedures. Methods A total of 194 patients scheduled for short-duration elective surgeries were randomly allocated into two groups. Group DK received a loading dose of 1 µg/kg of dexmedetomidine and 1 mg/kg of ketamine followed by a maintenance infusion of dexmedetomidine at 0.3 µg/kg/h. Group KP received a loading dose of 1 mg/kg of ketamine and 1 mg/kg of propofol followed by a maintenance infusion of propofol at 25 µg/kg/h. For procedural interference, a rescueketamine bolus was administered at 0.25 mg/kg. Patients were monitored for the requirement of rescue ketamine bolus, procedural interference, hemodynamics, sedation, recovery time, and adverse effects. Results The procedural interference was higher in group KP than in group DK and the difference was statistically significant (P=0.001). The time to the first rescue bolus was 8.72 ± 4.47 minutes in group KP and 10.82 ± 4.01 minutes in group DK, with a difference of 2.1 minutes (p=0.026). There was no statistically significant difference in the sedation scores between both groups except at time points of six minutes and 15 minutes. Conclusion For short-duration procedures, the DK combination is superior tothe KP combination in terms of procedural interference and time to the first rescue bolus, while both groups were comparable with regard to safety and hemodynamics.

Comparison of efficacy of low-dose norepinephrine infusion with low-dose boluses of norepinephrine in managing hypotension among parturients undergoing caesarean section under the subarachnoid block

: Spinal anesthesia is increasingly popular over general anesthesia due to several advantages. Hypotension can complicate spinal anesthesia during a cesarean section, which could have negative repercussions on the mother and fetus. This study is aimed to compare the efficacy of low-dose norepinephrine infusion with low-dose boluses of norepinephrine in managing hypotension among parturients undergoing cesarean section under subarachnoid block.: Ninety-nine parturients without comorbidities who underwent caesarean section with spinal anesthesia received norepinephrine were considered. They were divided into three groups. Group A- Parturient received a norepinephrine infusion of 1 mcg/min and a rescue bolus of 3 mcg to treat hypotension. Group B- Parturient received a Norepinephrine bolus of 3mcg to treat hypotension. Group C- Parturient received a Norepinephrine bolus of 5 mcg to treat hypotension. All the vitals at different intervals, number of norepinephrine boluses, the total amount of norepinephrine consumed, maximum sensory level achieved, time for baby extraction following subarachnoid block, and any adverse events were documented.No statistical difference was noted in the study group's demographics. However, there was a significant difference in mean systolic blood pressure between the groups from skin incision to baby extraction at T6 and T8. In addition, the mean arterial blood pressure of the two groups differed significantly throughout the period from baby extraction to skin suturing. Between the groups, there was a substantial difference in the total number of boluses needed. The total number of boluses required was maximum in group B, followed by group C. Group A required the minimum number of total norepinephrine boluses.A prophylactic norepinephrine infusion is an effective and straightforward method of reducing the incidence and magnitude of hypotension following spinal anesthesia for cesarean section with no adverse effect.

Comparison of Prophylactic Infusion of Phenylephrine Versus Norepinephrine for the Prevention of Post Spinal Hypotension in Parturients Undergoing Elective Caesarean Section-a Randomized, Double-Blinded, Non-Inferiority Trial.

Postspinal hypotension occurs in nearly 50% of women undergoing cesarean section (CS). Although phenylephrine (PE) is currently the vasopressor of choice, severe maternal bradycardia may adversely affect the fetal status due to the reduction in the maternal cardiac output. Norepinephrine (NE) is not associated with bradycardia and is now being evaluated for the treatment of post-spinal hypotension in obstetric patients. The hypothesis of this study was that the prophylactic NE infusion was non-inferior to PE infusion when used for the prevention of postspinal hypotension. This was a randomized, double-blinded controlled study conducted in 130 parturients scheduled for CS. The participants received either prophylactic NE (5 μg min-1) or PE (25 μg min-1) infusion beginning at the time of spinal injection. The primary outcome was the incidence of hypotension in both groups. Maternal bradycardia, reactive hypertension, nausea and vomiting, requirement of rescue boluses of vasopressor and/or atropine, and neonatal acid base status were also recorded. The incidence of hypotension was 33.80% (22 of 65) in Group PE and 26.10% (17 of 65) in Group NE (P=0.85). The absolute risk difference [90% confidence interval (CI)] in the incidence of hypotension between the groups was -7.7% (-20.9, 5.4). The upper limit of the CI was less than the non-inferiority margin of 20%, indicating that the NE infusion was non-inferior to PE. Prophylactic infusion of NE is not inferior to prophylactic PE infusion in the prevention of postspinal hypotension in patients undergoing CS.

Combined Programmed Intermittent Bolus and Patient-Controlled Bolus Is a More Favorable Setting for Epidural Pain Relief Than Continuous Infusion.

Epidural analgesia is a suitable and effective treatment for labor pain. However, the preferable modality setting for delivery remains debatable. This study adopted a programmed intermittent epidural bolus (PIEB) setting in conjunction with a patient-controlled epidural analgesia (PCEA) setting to improve the quality of labor analgesia and reduce the number of medical staff. We conducted a prospective observational analysis of primigravida parturients scheduled for spontaneous labor, which required epidural analgesia for painless labor. A total of 483 healthy primigravida parturients with singleton pregnancies were included in this cohort; 135 nulliparous patients were assigned to the continuous infusion setting (CEI) group and 348 to the PIEB + PCEA group. Compared to the CEI setting, the PIEB + PCEA setting significantly reduced the manual rescue by the clinician, extended the time required for the first manual rescue dose, and acclaimed good maternal satisfaction. The use of the CEI mode increased for poor performance requiring more than two rescues with an odds ratio of 2.635 by a binary logistic regression analysis. Using the PIEB + PCEA setting as the maintenance infusion had a longer duration for the first requested manual rescue, fewer manual rescue boluses, excellent satisfaction, and no significant increase in adverse events compared to the CEI setting.

SEE Question

Article| April 2023 SEE Question ASA Monitor April 2023, Vol. 87, 13. https://doi.org/10.1097/01.ASM.0000924956.59857.11 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation SEE Question. ASA Monitor 2023; 87:13 doi: https://doi.org/10.1097/01.ASM.0000924956.59857.11 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: cesarean section, fetus, hypotension, mothers, norepinephrine, phenylephrine, spinal anesthesia, systolic blood pressure, heart rate You are administering spinal anesthesia during an urgent cesarean delivery for a nonreassuring fetal heart rate. According to a recent study, which of the following outcomes is MOST likely in this parturient if you administer norepinephrine for maternal hypotension, compared to a similar parturient receiving phenylephrine? Guidelines from ASA and the Society for Obstetric Anesthesia and Perinatology recommend ephedrine or phenylephrine for treating maternal hypotension following spinal anesthesia for cesarean delivery. However, the guidelines also cite evidence that phenylephrine may more effectively treat hypotension and improve umbilical artery pH compared to ephedrine. Thus, phenylephrine – via preemptive infusion or rescue bolus – has gained favor in this setting. More recently, norepinephrine, with both α- and β-adrenergic agonist properties, has been explored as a potential replacement for phenylephrine. However, outcomes in relatively uncomplicated cesarean deliveries have been equivocal, and essentially no studies have compared these agents in the setting of potential... You do not currently have access to this content.

THE COMPARATIVE STUDY OF CRYSTALLOID PRELOAD V/S PHENYLEPHRINE &amp; CRYSTALLOID COLOAD FOR PREVENTING HYPOTENSION FROM SPINAL ANAESTHESIA FOR CESEREAN DELIVERY

Aim &amp; Objective: To compare the effectiveness of Crystalloid preload versus Phenylephrine &amp; crystalloid coload during lower segment cesarean section (LSCS) &amp; prevent hypotension following spinal anaesthesia. This randomized controlled hospital based stu Material &amp; Methods: dy was carried out in the Anaesthesiology Department, Rajshree Medical Research Institute Bareilly, Uttar Pradesh after the approval of proposal by subject committee &amp; Ethical Committee &amp; written informed consent. Results: The 2,4,6,8 &amp;10 mins interval mean SBP, DBP &amp;MAP,MHR,Mean Infusion rate,Mean Rescue Bolus was more among Group F (Phenylephrine Crystalloid Coload) compared to Group C (Crystalloid Preload Group). Conclusion: It was seen that Colloid preload is preferred over crystalloid preload to reduce the decrease in blood pressure by spinal anesthesia, requirement of the vasopressors , occurrence of nausea/vomiting in a pregnant female otherwise healthy going for elective caesarean delivery .

Ephedrine Infusion with Rescue Ephedrine Boluses versus Rescue Boluses alone for Preventing Hypotension during Spinal Anesthesia for Cesarean Delivery.

Background: Maternal hypotension is an unwanted consequence of the physiologic onset of spinal blockade, and causes both maternal and fetal effects. Maternal symptoms include nausea, vomiting, and a sense of ‘‘impending doom’’ from inadequate cerebral perfusion. Inadequate treatment of hypotension can ultimately end with the loss of consciousness and cardiovascular collapse.&#x0D; Materials and methods: We included 80 full term parturient (ASA I or II) with uncomplicated pregnancies. The patients were prospectively randomized into two groups. 80 patients received 1000 mL NaCl 0,9 % solution before the initiation of spinal anesthesia. Maternal systolic blood pressure was measured every 1 minutes (for first 10 minutes) and then every 3 minutes. One group received ephedrine infusion (1 mg/min) with rescue ephedrine boluses (10 mg), (usually defined as a maternal blood pressure ˂ 30% above baseline), (40 patients) and the other received rescue boluses alone (10 mg) , (usually defined as a maternal blood pressure ˂ 30% above baseline), (40 patients).&#x0D; Results: Gr 1 (Ephedrine infusion with rescue ephedrine boluses). The incidence of hypotension was at 8 patients (8/40 [20%]),(when an absolute value of less than 90 mmHg).&#x0D; Gr 2 (rescue boluses ephedrine alone). The incidence of hypotension was at 32 patients (32/40 [80%]), (when an absolute value of less than 90 mmHg).&#x0D; Group 2 had a higher incidence of hypotension compared with group 1 (32/40 [80%]) vs (8/40 [20%]).&#x0D; Neonatal outcomes were not different between the 2 groups.&#x0D; Conclusion: Prophylactic variable rate ephedrine infusion and rescue ephedrine bolus dosing is more effective than relying on rescue ephedrine bolus dosing with respect to limiting clinician workload and maternal symptoms during spinal anesthesia for cesarean delivery.Maternal hypotension

Effect of intravenous lidocaine on the ED50 of propofol for inserting gastroscope without body movement in adult patients: a randomized, controlled study

BackgroundCirculatory and respiratory depression are common problems that occur in propofol alone sedation during gastroscopy. As a widely used analgesic adjuvant, intravenous lidocaine can reduce the consumption of propofol during Endoscopic retrograde cholangiopancreatography (ERCP) or colonoscopy. However, it is still unknown the median effective dose (ED50) of propofol when combined with lidocaine intravenously. This study aimed to compare the ED50 of propofol with or without intravenous lidocaine for inserting gastrointestinal endoscope successfully.MethodsFifty nine patients undergoing gastroscopy or gastrointestinal (GI) endoscopy were randomly divided into control group (Group C, normal saline + propofol) or lidocaine group (Group L, lidocaine + propofol). Patients were initially injected a bolus of 1.5 mg/kg lidocaine in Group L, whereas equivalent volume of 0.9% saline in Group C. Anaesthesia was then induced with a single bolus of propofol in all subjects. The induction dose of propofol was determined by the modified Dixon’s up-and-down method, and the initial dose was 1.5 mg/kg in both groups. The primary outcome was the ED50 of propofol induction dose with or without intravenous lidocaine. The secondary outcomes were the induction time, the first propofol bolus time (FPBT: from MOAA/S score ≤ 1 to first rescue bolus propofol), and adverse events (AEs: hypoxemia, bradycardia, hypotension, and body movements).ResultsTotally, 59 patients were enrolled and completed this study. The ED50 of propofol combined with lidocaine was 1.68 ± 0.11 mg/kg, significantly reduced compared with the normal saline group, 1.88 ± 0.13 mg/kg (P = 0.002). There was no statistical difference in induction time (P = 0.115) and the FPBT (P = 0.655) between the two groups. There was no significantly difference about the AEs between the two groups.ConclusionThe ED50 of propofol combined with intravenous lidocaine for successful endoscope insertion in adult patients, was 1.68 ± 0.11 mg/kg significantly reduced compared with the control group.Trial registrationChinese Clinical Trial Registry, No: ChiCTR2200059450. Registered on 29 April 2022. Prospective registration. http://www.chictr.org.cn.