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A case of intra- and retroperitoneal haemorrhage after a splenic vein aneurysm rupture is described. A 27-year-old woman complained of chest pain on her first postpartum day. Symptoms were initially suggestive of pulmonary embolism, but within 3 h she developed severe acute abdominal pain, abdominal distension and haemodynamic instability. Ultrasound demonstrated a non-echogenic mass in the abdomen suggestive of a fluid collection and a computed tomography scan confirmed the presence of a lesion at the pancreatic tail. Urgent laparotomy revealed splenic vein rupture near the pancreatic tail. Partial pancreatectomy and splenectomy were performed. The patient subsequently made an uneventful recovery. Histological examination revealed a splenic vein aneurysm and chronic inflammatory changes in the pancreatic tissue. Rupture of a splenic vein aneurysm is a rare event and the diagnosis may present difficulty because its presentation is similar to several other more common conditions. However, rupture of a splenic vein aneurysm should be suspected in any pregnant woman with unexplained abdominal pain or with clear signs of haemorrhage, as delay in diagnosis can have devastating consequences.

We determined the minimum local anaesthetic dose (MLAD) of spinal levobupivacaine and ropivacaine for Caesarean section. Ninety women were randomly allocated to two groups and received 3 ml of study solution by a combined spinal/epidural technique. The initial dose was 12 mg for levobupivacaine and 17 mg for ropivacaine groups. To be considered effective, a test solution had to achieve a visual analogue pain score (VAPS) of 30 mm or less at skin incision, uterine incision, birth, peritoneal closure, and at the end of surgery. Effective or ineffective responses determined, respectively, a 0.3 mg decrease or increase of the same drug for the next patient in the same group, using up-down sequential allocation. The MLAD of levobupivacaine was 10.58 mg (CI 95\%: 10.08-11.09) and the MLAD of ropivacaine 14.22 mg (CI 95\%: 13.67-14.77), using the Dixon and Massey formula. The potency ratio between spinal levobupivacaine and spinal ropivacaine was 1.34.

Many techniques used to investigate the epidural region may alter the anatomy. Magnetic resonance imaging (MRI) has been introduced as a non-invasive diagnostic technique. The aim of this study was to investigate the anatomy of the lumbar epidural region using MRI, studying the morphology, the dimensions and the modification that may result from a change of position. Ten young, healthy female volunteers were studied to obtain results relevant to obstetric anesthesia. The following measurements were made: anterior epidural space (AES); posterior epidural space (PES); ligamenta flava; distance between the PES and the skin (S-ES); and interspace distance (ISD). All these distances were measured with the subject supine and the lumbar spine either in a neutral or a non-lordotic (flexed) position. The S-ES ranged from 2.7 to 8.1 cm. This distance was greater in the lower than in the upper lumbar segments. No differences were observed in AES, PES and ligamenta flava between the neutral and flexed positions. Flexion of the spine did not affect the S-ES but increased the ISD (P0.05). The S-ES at any lumbar segment or interspace and the thickness of ligamenta flava at the L2/3 interspace correlated significantly with body weight (respectively, P0.01 and P0.02). In conclusion, MRI may clearly reveal the anatomy of the epidural region. The circumferentially and metamerically segmented compartments of the epidural space were clearly noted and measured. Ligamenta flava seem to be thinner in younger than in older subjects. This may partly explain a reduced loss of resistance sometimes perceived in obstetric patients.

Puerperal women are reported to have a rate of cerebral infarction 13 times greater than non-pregnant females. We report a case of cerebral ischaemia in a 30-yr-old healthy parturient after epidural analgesia for labour, complicated by dural puncture treated with two epidural blood patches. Investigations showed the development of cerebral ischaemia on postpartum day 14. A transcranial Doppler ultrasonography showed vasospasm of the left middle cerebral artery still present at 3-month follow-up. At 1-yr follow-up, the patient had homonymous hemianopsia. We discuss the possible causative mechanism of the cerebral ischaemia in relation to the dural puncture and epidural blood patch.

We have used the technique of double-blind sequential allocation to quantify the minimum local analgesic concentration (MLAC) of extradural bupivacaine for women in early (median cervical dilatation 2 cm) and late (median cervical dilatation 5 cm) labour. The first bolus was 20 ml of the bupivacaine test solution. The concentration was determined by the response of the previous woman to a higher or lower concentration of bupivacaine according to up and down sequential allocation. Efficacy was assessed using a 100-mm visual analogue pain score (VAPS). The test solution had to achieve a VAPS of 10 mm or less to be judged effective. In early labour, the MLAC of bupivacaine was 0.048% w/v (95% confidence intervals (CI) 0.037-0.058% w/v), and 0.140% w/v (95% CI 0.132-0.150% w/v) in the late group. The MLAC of bupivacaine in late labour was greater by a factor of 2.9 (95% CI 2.7-3.2) compared with the MLAC in early labour (P0.0001, 95% CI difference 0.08-0.11). We conclude that advancing labour requires an increased concentration of extradural bupivacaine for pain relief.

The low cardiovascular and neurological toxicity of levobupivacaine has led to its application as a local anaesthetic in a wide variety of specialist applications including peribulbar block for cataract surgery. The aim of this study was to evaluate the efficacy of levobupivacaine 0.5% and to compare block quality vs. ropivacaine 0.75% in peribulbar anaesthesia.We examined 208 patients subjected to cataract surgery by phacoemulsification who were randomized into two groups according to the anaesthetic used for peribulbar block, namely levobupivacaine 0.5% or ropivacaine 0.75%, both with the addition of hyaluronidase. Nerve block was carried out by injection of 6 mL of the anaesthetic mixture equally distributed between the inferotemporal and superonasal areas. The success of the block was evaluated by determining the time of motor and sensory onset, akinesia score, times of motor and sensory offset and satisfaction of the patient and surgeon after 24 h. Pre-block, post-block and postoperative intraocular pressure as well as the duration of surgical intervention was also determined.With respect to ropivacaine, levobupivacaine showed a significant reduction (P0.001) in the average motor and sensory onset. Both the akinesia score (P0.01) and mean motor and sensory offset times were also higher (P0.001). Neither the average intervention times nor the satisfaction of the patient/surgeon showed any significant differences between the two groups.Levobupivacaine (0.5%) has better anaesthetic properties with respect to 0.75% ropivacaine and is well-suited for peribulbar block in cataract surgery.

Puerperal women are reported to have a rate of cerebral infarction 13 times greater than non-pregnant females. We report a case of cerebral ischaemia in a 30-yr-old healthy parturient after epidural analgesia for labour, complicated by dural puncture treated with two epidural blood patches. Investigations showed the development of cerebral ischaemia on postpartum day 14. A transcranial Doppler ultrasonography showed vasospasm of the left middle cerebral artery still present at 3-month follow-up. At 1-yr follow-up, the patient had homonymous hemianopsia. We discuss the possible causative mechanism of the cerebral ischaemia in relation to the dural puncture and epidural blood patch.

The aim of this study was to determine the ED50 for the dose of levobupivacaine 0,5% that, if given intrathecally will not cause total spinal anesthesia but will give a reliable and reproducible clinical sign to differentiate intrathecal from epidural injection.Thirty women at term undergoing elective cesarean section under a combined spinal-epidural technique (CSE) were enrolled into this sequential allocation study. The dose in each test dose was determined by the response of the previous patient to the higher or lower dose in her test syringe, according to up-down sequential allocation. The exception to this was the first woman in each group, for whom the starting dose was chosen to be 4 mg. The end point was the occurrence of any motor block, in any side, within 5 minutes from intrathecal injection of the test dose. Test dose efficacy was assessed using a modified Bromage scale every minute for 5 minutes. The median effective dose of levobupivacaine was estimated from the up-down sequences using the formula of Dixon and Massey.The MAD of the test dose for levobupivacaine was of 4,8 mg (4,4 to 5,2; 95% C.I.).This study may help to determine the appropriate dose for a test dose for inadvertent spinal levobupivacaine.

All epidural or spinal techniques using local anaesthetics causes some degree of sympathetic blockade resulting in peripheral vasodilatation and possibly hypotension or reduction in cardiac output. In the practical clinic, administration of fluids intravenously prior spinal and epidural anaesthesia is required to prevent maternal hypotension and fetal hypoxia. We evaluated in this review the efficacy of volume preloading on the incidence of hypotension after spinal or epidural anaesthesia for caesarean delivery. Randomized controlled trials investigating volume preloading before the initiation of obstetric anaesthesia were sought by using MEDLINE (1966-2001). The primary outcome was the incidence of hypotension. Secondary outcomes included: ephedrine use, Apgar scores, umbilical cord pH values, and maternal nausea and vomiting. Crystalloid preload was inconsistent in preventing hypotension, whereas colloid appeared to be effective in all studies. A colloid solution, such as hydro-xyethyl starch (HES) might be preferable considering the capacity to stay intravasculary for a longer period. Few differences in fetal outcomes or maternal nausea and vomiting were reported. Increasing central blood volume by using colloid decreases the incidence of hypotension before loco-regional anaesthesia for cesarean delivery. Implications. We performed a review to determine whether fluid loading reduced the incidence of low blood pressure after spinal or epidural anaesthesia for caesarean delivery. Although no technique totally eliminates the occurrence of hypotension, colloid administration (starch or gelatin containing fluids) was the most effective.

Published studies, including abstracts, has been reviewed and summarized.Studies in sheep have demonstrated no significant differences in pharmacokinetic and placental transfer of levobuvacaine when compared with bupivacaine. Clinical studies on cesarean section confirmed similar performance between these two drugs. No differences in onset time, sensory and motor block and efficacy of analgesia have been reported. Two multicentre studies on labor analgesia reported again similar analgesic efficacy with a trend toward less motor block in parturients receiving levobupivacaine.This review has shown that levobupivacaine has a similar efficacy and a similar maternal fetal safety to that of bupivacaine. Further studies are needed to determine if the chemical properties of the new agent may influence the sensory and motor characteristics of the block.

The aim of this prospective, double-blind, sequential allocation study was to compare the effects of spontaneous and prostaglandin-induced labor on the minimum analgesic dose of epidural sufentanil in the first stage of labor.Seventy healthy, nulliparous women, at more than 37 weeks' gestation with cervical dilatation from 2 to 4 cm, requesting epidural pain relief in labor were enrolled. The subjects were assigned to two different groups according to whether labor was spontaneous or induced with dinoprostone 0.5 mg. Parturients received 10 ml of the study solution through a lumbar epidural catheter. The initial dose was sufentanil 25 microg, and subsequent doses were determined by the response of the previous patient in the same group using up-down sequential allocation. The analgesic effectiveness was assessed using 100-mm visual analog pain scores. The up-down sequences were analyzed using the method of independent paired reversals and probit regression.The minimum analgesic dose of sufentanil in spontaneous labor was 22.2 microg (95% CI: 19.6, 22.8) and 27.3 microg (95% CI: 23.8, 30.9) in induced labor. The minimum analgesic dose of sufentanil in induced labor was significantly greater (P = 0.0014) than that in spontaneous labor (95% CI difference: 2.9, 9.3) by a factor of 1.3 (95% CI: 1.1, 1.5).Prostaglandin induction of labor produces a significantly greater analgesic requirement than does spontaneous labor.

The main problem with emergency caesarean section is the rapid induction of anaesthesia in a potentially unstable and unknown patient.

Pregnancy represents a unique alteration in physiology that usually ends in its completion without complication. Sometimes however, in certain instances, lifethreatening complications occur which require intensive care with invasive monitoring and mechanical ventilation.

A number of clinical studies have been performed in an attempt to establish the effects of alkalinization on potency of local anesthetics. Conflicting results were obtained probably because different studies used different methods as well as different definitions of the effects. To determine the efficacy of alkalinization using different local anesthetic solutions and different regional blocks, 180 patients were studied in a randomized, double-blind fashion. The local anesthetic solutions studied were bupivacaine, mepivacaine, and lidocaine; the regional blocks studied were epidural block, axillary brachial plexus block, and femoral and sciatic nerve block.In this study, 180 patients receiving epidural block (n = 60), sciatic and femoral nerve block (n = 60), and brachial plexus block (n = 60) were randomized to receive, in a double-blind fashion, a plain or a pH-adjusted solution of 2% mepivacaine, 2% lidocaine, or 0.5% bupivacaine. Onset of sensory analgesia, onset of maximum effect (peak effect or complete analgesia), duration of the block, onset, duration and density of motor block were evaluated using pinprick (Hollmen scale) and a 10-point decimal scale (Seow scale).concerning epidural block, the alkalinization of the local anesthetic shortened significantly the onset of sensory analgesia in the dermatome corresponding to the lumbar interspace used for epidural puncture (L3-L4) and increased the spread of the epidural block in all the groups. The onset of sensory analgesia at L4 level ranged from 10 minutes for plain bupivacaine to 3 minutes for alkalinized lidocaine, whereas the onset at T10 level ranged from 16 minutes for plain bupivacaine and mepivacaine to 12.3 minutes for alkalinized lidocaine. The effects of alkalinization were more evident with lidocaine and bupivacaine. Concerning femoral and sciatic nerve blocks, a statistically significant shorter onset of sensory analgesia and motor block were observed with mepivacaine. Concerning brachial plexus axillary block, the effects of alkalinization were more evident with lidocaine.Alkalinization produced the best results with lidocaine and bupivacaine for epidural block, with lidocaine for brachial plexus block, and with mepivacaine for sciatic and femoral nerve blocks.

Epidural anesthesia has more flexibility than either general or spinal anesthesia for cesarean section. Its benefits extend through both intraoperative and postoperative periods. Advantages and disadvantages versus general or spinal, and more recently, combined epidural-spinal anesthesia are well documented.’ One of the major concerns about epidural anesthesia for cesarean section is the frequent occurrence of intraoperative discomfort. This problem may require adjunctive measures and, depending on the severity of pain, general anesthesia may occasionally become necessary. Discomfort may be defined as a sensation of pressure, heaviness, tightness or squeezing that does not require treatment, because of its short duration or because it is tolerated or accepted by the patient. Intraoperative pain may be moderate, short-lasting and easily treated by additional medications, or severe, long-lasting and requiring conversion to general anesthesia. The percentage of patients experiencing intraoperative pain requiring additional analgesic medications during surgery varies considerably, depending on the local anesthetic used and on the epidural technique, and ranges from 10-50%.2~3 Knowledge of the factors causing intraoperative discomfort or pain, and the possible solutions, may greatly improve the efficiency and thus the reliability of epidural anesthesia for cesarean section. The aim of this article is to review the most common causes of intraoperative maternal discomfort and pain and to suggest possible solutions in order to improve the success of epidural anesthesia for cesarean section.

The purpose of this study is to evaluate the effects of puncture of lumbar dura mater with needles of different sizes and with bevels of different shapes.After removal, the dura was punctured with different needles (22-, 25-, 27-, and 29-gauge Quincke, 24-gauge Sprotte, 22-gauge Whitacre, and 18-gauge Tuohy needles) and observed by stereomicroscope to examine the gross morphology. Histologic features were observed by light microscope using frozen and fixed samples stained with hematoxylin and eosin or specific methods (Masson and Weigert) to evidence elastic or collagen fibers.Puncture hole size was proportional to the size of the needle used. Quincke type needles determined oval or ellipsoidal holes; pencil-point needles determined more rounded holes. Dural retraction determined a reduction of the holes in all cases. Histologic examination revealed an irregular border of the hole, with sectioned as well as compressed fibers. The pattern of compressed but not sectioned fibers was observed more frequently in the samples punctured by pencil-point needles.This study confirms that the arrangement of dural fibers is not as uniform as previously thought. Histologic findings confirm the current opinion that pencil-point needles may be less traumatic than Quincke-type needles. The direction of the bevel of the needle does not appear to have great importance in determining the shape of the hole.

Twenty eight elderly patients scheduled for urologic surgery were randomly assigned to receive in a double blind fashion subarachnoid hyperbaric bupivacaine 15 mg with the addition of 50 micrograms (group A, n = 7), 25 micrograms (group B, n = 7), 12.5 micrograms (group C, n = 7), of fentanyl or 1 ml of saline (group D, n = 7) for a total volume of 4 ml. The pattern of breathing and the ventilatory response to CO2 were studied before 90, 150, 480 minutes after the subarachnoid injection. In group A mild pruritus and sedation occurred in 5 patients, nausea, vomiting and periodic breathing occurred in 2 patients. In group B mild pruritus and sedation were observed in 4 patients, nausea, vomiting in 2 patients. No significant changes in VE, Vt/Ti and Ti/Ttot were observed between the groups. Patients receiving 50 micrograms of fentanyl showed a slope VE/PET CO2 significantly below baseline values at 90 and 150 minutes (p less than 0.05). In this group the baseline values were restored after 480 minutes. No side effects were observed in group C and D. 25 micrograms fo fentanyl is the only dose with a significant analgesic effect without any respiratory depression.

A randomized, double-blind study was designed to determine the effects on maternal intraoperative analgesia of adding one of the following opioids to the local anesthetic at the onset of epidural block, before surgery and neonatal delivery: morphine (3 mg), fentanyl (75 micrograms), sufentanil (50 micrograms), buprenorphine (0.3 mg) and oxymorphone (1 mg). The duration of postoperative analgesia, the presence of side effects and the neonatal outcome were also studied. Ninety healthy multiparas, at term, undergoing elective cesarean delivery using lumbar epidural anesthesia with 2% lidocaine were randomized in six equal groups to receive one of the opioids or saline. The predelivery administration of morphine, fentanyl and sufentanil significantly improved the intraoperative analgesia. Patients who received fentanyl, sufentanil, buprenorphine or oxymorphone had more somnolence than the others (p less than 0.01), but this did not interfere with the first mother-infant relationship during surgery. Patients in the buprenorphine group had more vomiting during surgery when compared with the others (p less than 0.01). Morphine provided the longest pain-free interval, followed by oxymorphone, buprenorphine, sufentanil and fentanyl. Postoperatively, the number of patients having pruritus and vomiting was significantly higher in the morphine and buprenorphine groups, respectively (p less than 0.01 versus others). No adverse neonatal effects were noted in any group.

Background and objective: The study was designed to evaluate whether the administration of sevoflurane in 100% oxygen for anaesthesia during Caesarean section would improve fetal and neonatal oxygenation compared with the administration of sevoflurane with 50% nitrous oxide in oxygen. Methods: The randomized, single-blind controlled study examined 24 mothers, ASA I-II, at term undergoing Caesarean section who were allocated to receive sevoflurane in either 100% oxygen (n = 13) or 50% nitrous oxide in oxygen (n = 11). General anaesthesia was induced in both groups with thiopental 4-5 mg kg -1 followed by succinylcholine 1.5 mg kg -1 to facilitate tracheal intubation. Parturients received sevoflurane given either in 100% O 2 or in a 50: 50 nitrous oxide and oxygen mixture, using 0.5-1.0% progressive incremental dosing up to 1.5-2.0 MAC. Non-invasive fetal oxygen saturation was measured between induction to delivery, and umbilical artery and vein PaO 2 were evaluated at birth. Results: Intraoperative fetal oxygen saturation increased in all patients after maternal 100% oxygen administration (P < 0.01). Maternal hyperoxygenation significantly increased the umbilical vein and umbilical artery PaO 2 and the umbilical artery SaO 2 at birth (P < 0.0001). Conclusions: Maternal hyperoxygenation significantly improves fetal as well as neonatal oxygenation.

The treatment of a critical respiratory insufficiency during a decompensated phase can cause a prolonged period of mechanical ventilation. So a tracheostomic access may be necessary in order to continue the weaning process from the ventilator. In our study we wanted to evaluate the mobility of the true vocal chords and occurrence of the dyslocation of cricoarytenoid cartilage after the percutaneous tracheostomy with the Fantoni technique, which we applied on 70 patients from 1997 until 2001. All 70 patients were treated with the same tracheal access method in the space between the first and the second tracheal ring. Our study required an endoscopic evaluation protocol with a direct fibrolaringoscopic access to the patient. So we evaluated the conformation of the upper respiratory-digestive ways and the mobility of the larynx and of the vocal chords (precisely: symmetric movement in adduction and abduction of vocal folds) and occurrence of cricoarytenoid cartilage lesion. We repeated the measurements 7 days after the intervention when we substituted the endotracheal cannule (Time 1) and after 20 days (Time 2). In the follow up we controlled our patients 2 months after the tracheostomy (Time 3) to find out about eventual anatomic and functional changes of the larynx. Considering the patient's condition we then decided about the possible weaning from the tracheostomic cannule. Exclusion criteria from patient enrollment were: 1. Patients affected by severe neurologic pathology in which the damage of the central nervous system could eventually interfere with the mobility of the upper respiratory-digestive ways. 2. Patients affected by severe peripheral neuropathy. 3. Patients with previous surgery of the larynx, the thyroid gland and the laterocervical areas (lymphadenectomy, carotid endarteriectomy, etc.)

We have studied the efficacy of i.v. clonidine to suppress post-extradural shivering in parturients. Forty healthy parturients who received extradural block for labour (n = 20) or for Caesarean section (n = 20) and who required treatment for shivering after delivery were allocated randomly to two groups. Group I received i.v. clonidine 30 micrograms diluted in saline to a total volume of 5 ml (therapeutic solution). This bolus was repeated every 5 min if the initial therapy produced no improvement, up to a maximum dose of 90 micrograms. Group II received saline 5 ml (placebo solution), repeated every 5 min if the initial bolus produced no improvement, up to a maximum of three boluses. After 15 min of observation, patients in group I received the placebo solution and those in group II received the study solution. All patients who received clonidine improved, and 75% ceased to shiver within 5 min after only one dose of clonidine 30 micrograms. In contrast, none of the patients treated with saline improved. When patients in the placebo group received clonidine, improvement occurred. Arterial pressure, heart rate, core and peripheral temperature and oxygen saturation did not differ significantly between and within the groups before and after administration of clonidine. We conclude that a small dose of i.v. clonidine may be useful to suppress post-extradural shivering in parturients.