In a double-blind, randomized trial, 98 parturients undergoing cesarean section received either hyperbaric or plain bupivacaine 6.6 mg combined with sufentanil 3.3 [micro sign]g as part of a combined spinal-epidural procedure. To prevent hypotension, 1000 mL of lactated Ringer's solution, 500 mL of hydroxyethyl starch 6%, and ephedrine 5 mg were administered IV. The height of the block was equal in both groups, but more patients in the plain group had blocks that were either too high or too low (P < 0.01). The number of patients requiring epidural supplementation was equal in both groups. Strict criteria were used to treat hypotension. The overall incidence of systolic blood pressure (<90 mm Hg) was 13%, whereas it was more pronounced in the plain group (21% vs 6% in the hyperbaric group, P < 0.05), which required more ephedrine (P < 0.05) and in which a greater incidence of nausea was noticed (P < 0.05). We conclude that the use of a small dose of intrathecal bupivacaine combined with sufentanil plus our described preloading regimen resulted in a lower incidence of hypotension. Further, we conclude that the use of hyperbaric bupivacaine in this manner provides a more reliable block and a lower incidence of hypotension than plain bupivacaine. Implications: A small dose of hyperbaric bupivacaine 0.5% combined with sufentanil used intrathecally during cesarean section offered a more reliable cephalad spread of the spinal block than the glucose-free combination, which was reflected in a lower incidence of hypotension and nausea. (Anesth Analg 1998;86:989-93)
Background: Postspinal hypotension is a frequent maternal complication in caesarean delivery under neuraxial anesthesia. Anesthesiologists have been using different vasopressors to maintain hemodynamics. Recent studies suggested beneficial effects of norepinephrine on maternal blood pressure and cardiac output, but little evidence exist on the neonatal outcome. Objectives: This systematic review summarises recent evidence on neonatal outcome, such as umbilical arterial pH and base excess, after administration of norepinephrine during caesarean section. Methods: A literature search on PubMed from 2010 to 2022 was performed and every article was reviewed on neonatal outcome, as primary endpoint and on maternal hemodynamics, as secondary endpoint. A total of 15 randomised controlled trials were included. Results: Studies using a prophylactic infusion of norepinephrine show normal fetal blood gases. No evidence of fetal stress (pH < 7,20, base excess < -6) was assessed in the studies. Norepinephrine succeed in maintaining maternal hemodynamics. It is responsible for less bradycardia than phenylephrine and less tachycardia than ephedrine. Conclusion: Our study suggests that norepinephrine, preferably as prophylactic infusion, is a safe vasopressor to prevent postspinal hypotension in caesarean section. No signs of fetal acidosis could be demonstrated in the recent studies.
Background: The large surgical incision and extensive tissue trauma in posterior spinal fusion for adolescent idiopathic scoliosis causes severe acute postoperative pain. Furthermore, posterior spinal fusion is associated with a risk of persistent postsurgical pain. Six months after posterior spinal fusion, the incidence of persistent postsurgical pain is as high as 22% of the patients. Optimizing pain management therefore remains crucial, but challenging. Objective: The study objective is to design and implement an enhanced recovery pathway for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion integrating all aspects of biopsychosocial care. Its outcomes are assessed, including its effect on postoperative pain and early mobilization. Design and settings: A prospective cohort study was performed at the Antwerp University Hospital. Methods: In December 2019, a prospective cohort study was set up in which an enhanced recovery pathway substitutes more than the patient controlled intravenous analgesia containing morphine postoperatively. This pathway consists of m/eHealth based psychological screening questionnaires, patient education, early mobilization, and a multimodal analgesia protocol consisting of preemptive gabapentin, an intraoperatively given single dose of methadone (0.2 mg kg-1), non-steroidal anti-inflammatory drugs, and acetaminophen. Results: We treated 25 adolescents (10 males and 15 females) with the developed enhanced recovery pathway with a mean age of 16.5 years (range 12-22). The mean number of spinal levels fused was 10 (range 6-13). Mean numerical rating scale scores were 4.17 at postoperative day 1, 4.46 at postoperative day 2, and 3.74 at postoperative day 3 in enhanced recovery pathway treated patients. Mean bladder catheterization duration was 3.04 days and enhanced recovery pathway patients stayed in the hospital for an average of 7.4 days. Conclusions: Using an enhanced recovery pathway for patients undergoing posterior spinal fusion could not only reduce the acute and chronic opioid consumption and its side effects, but could also result in less postoperative pain, shorter hospital stay and higher patient satisfaction. Further reevaluation and improvement focused on these variables will likely further improve the effectiveness of enhanced recovery pathways. Trial registration: ClinicalTrials.gov NCT04038229.
BackgroundPaired sampling of acute (aST) and basal (bST) serum tryptase has been recommended when investigating patients with a suspected perioperative hypersensitivity (POH) reaction. In the current consensus formula, an aST value exceeding (1.2×bST+2) confirms mast cell activation. The current consensus formula has been validated in adults but not in children.MethodsWe prospectively included 96 children who underwent uneventful anaesthesia and sampled serum tryptase at baseline and 60–90 min after induction. Tryptase changes were then compared with those in 94 children with suspected POH who were retrospectively included from four reference centres in Belgium, France, and Denmark.ResultsWe observed a median decrease in serum tryptase during uneventful anaesthesia of 0.41 μg L−1 (–15.9%; P<0.001). The current consensus formula identified mast cell activation in 31.9% of paediatric POH patients. After generating receiver operating characteristic curves through 100 repeated five-fold cross-validation, aST>bST+0.71 was identified as the optimal cut-off point to identify mast cell activation. This new paediatric formula has higher sensitivity than the current consensus formula (53.2% vs 31.9%, P<0.001) with a specificity of 96.9%. Analysis in the subpopulation where a culprit was identified and in grade 3–4 reactions similarly yielded higher sensitivity for the new paediatric formula when compared with the current consensus formula (85.3% vs 61.8%; P=0.008 and 78.0% vs 48.8%; P<0.001, respectively). Internally cross-validated sensitivity and specificity were 53.3% and 93.3%, respectively.ConclusionsThis is the first study suggesting the need for an adjusted formula in children to identify perioperative mast cell activation as tryptase is significantly lowered during uneventful anaesthesia. We propose a new formula (aST>bST+0.71) which performs significantly better than the current consensus formula in our multicentric paediatric population.
In Brief Target-controlled infusion (TCI) of rocuronium can be used to maintain a stable blood concentration (Cp). At steady-state, the pharmacokinetics (PK) are compensated for by TCI, and a stable effect can be observed. The theoretical Cp may represent effect-site concentration (EC). We used the EC-effect relationship to study pharmacodynamics (PD) in infants, children, and adults. After giving their written, informed consent, 14 infants, 23 children, and 21 adults scheduled for elective surgical procedures received 3 to 6 ascending Cp targets of TCI rocuronium according to PD data. Just before each increase of TCI, venous blood samples were taken to measure Cp. Neuromuscular block was evaluated acceleromyographically. Individual effect data and measured Cp were fitted to the Hill equation. Maximum block during TCI targets—1000, 1300, and 1600 ng/mL—was smaller in children in comparison with infants and adults. The concentration in the effect compartment associated with a 50% drug effect (EC50) was significantly smaller in infants (mean [sd]) (652 [215] ng/mL) than in adults (954 [276] ng/mL) and was the largest in children (1200 [295] ng/mL). Calculated mean EC90 values were 1705, 2230, and 2035 ng/mL, respectively, in infants, children, and adults. TCI rocuronium established steady-state PK/PD at different TCI targets and allowed us to define PK/PD relationships in a standardized way. Steady-state TCI rocuronium revealed the most potency of rocuronium in infants and the least in children. IMPLICATIONS: Target-controlled infusion (TCI) of rocuronium in infants, children, and adults was used to analyze the pharmacokinetic/pharmacodynamic relationship. Steady-state TCI rocuronium revealed the most potency of rocuronium in infants and the least in children.
