Article

Intraperitoneal chloroprocaine is a useful adjunct to neuraxial block during cesarean delivery: A case series

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Abstract

Background: Use of intraperitoneal local anesthetic to treat intraoperative pain during cesarean delivery has not been described previously. The aim of this study was to determine if intraperitoneal chloroprocaine may be useful as an adjunct to neuraxial block in reducing the proportion of patients with severe intraoperative pain that requires conversion to general anesthesia. Intraperitoneal chloroprocaine was administered during cesarean delivery as a potential alternative, when the anesthesiologist considered performing a general anesthetic due to severe intraoperative pain. Methods: A keyword search for "chloroprocaine" was performed for patients on labor and delivery between November 2013 and March 2017. Patients were included if cesarean delivery was initiated with neuraxial anesthesia and there was documented intraoperative intraperitoneal instillation of chloroprocaine. Results: Among 2479 patients who had cesarean delivery with neuraxial anesthesia, 32 received intraperitoneal chloroprocaine (mean dose 11.8 mg/kg). No patients exhibited signs of local anesthetic systemic toxicity or required conversion to general anesthesia. Among the 32 patients who received chloroprocaine, 17 had improved pain scores documented after instillation. Conclusion: Intraperitoneal chloroprocaine may be useful as part of a multimodal approach to managing intraoperative pain during cesarean delivery.

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... 110 More recently, Werntz et al. reported a case series describing the use of intraperitoneal instillation with 3% chloroprocaine as a rescue technique for intra-operative pain in women having CD under neuraxial anaesthesia. 111 In this case series of 32 women, an average of 11.8 mg/kg chloroprocaine was used to treat intra-operative pain: 53% of patients reported a significant improvement in pain scores and no patients requiring conversion to GA. Although results from this case series suggest that intraperitoneal instillation may be a useful treatment for managing intraoperative CD pain, randomised controlled trials evaluating this technique are needed before it can be incorporated into standard practice. ...
Article
In this narrative review we summarise pertinent data from published studies investigating the use of local anaesthetic techniques as adjuncts for managing post-caesarean delivery pain. Based on currently available evidence, ultrasound-guided transversus abdominis plane (TAP), quadratus lumborum (QL) and ilio-inguinal and iliohypogastric (ILIH) blocks are preferable to landmark techniques. When intrathecal morphine is used for caesarean delivery analgesia, TAP blocks do not confer any additional benefit. In the absence of intrathecal morphine, TAP blocks have been shown to reduce pain scores and opioid consumption in the first 24 h postoperatively. In the absence of intrathecal morphine, single-dose local anaesthetic wound infiltration also results in a moderate reduction in opioid consumption postoperatively. If a wound catheter is to be incorporated into a multimodal analgesic regimen, a position below the fascia and a continuous infusion of low-concentration local anaesthetic solutions should be considered. Intraperitoneal local anaesthetic instillation may be of benefit in patients who undergo peritoneal closure but larger studies are still needed. Quadratus lumborum and ILIH blocks show promising results but the data are limited, so recommendations for routine use cannot be made. In summary, evidence supports the use of local anaesthetic techniques for post-caesarean delivery pain but additional research is required to determine the optimum dosing regimens, and the potential role of liposomal local anaesthetics. Further studies are required to compare techniques and determine their role in conjunction with low-dose long-acting neuraxial opioids.
Article
Background: Intraperitoneal chloroprocaine has been used during cesarean delivery to supplement suboptimal neuraxial anesthesia for decades. The short in vitro half-life of chloroprocaine (11-21 seconds) has been cited to support the safety of this approach. However, there are no data regarding the rate of absorption, representing patient drug exposure, through this route of administration. Accordingly, we designed a study to determine the in vivo half-life of intraperitoneal chloroprocaine and assess clinical tolerability. Methods: We designed a single-center, prospective, cohort, multiple-dose escalation study of women 18 to 50 years of age undergoing cesarean delivery with spinal anesthesia. Chloroprocaine (40 mL) was administered after delivery of the newborn and before uterine closure. The first cohort (n = 5) received 1%, the second cohort (n = 5) received 2%, and the third cohort (n = 5) received 3% chloroprocaine solution. Maternal blood samples were obtained before administration and 1, 5, 10, 20, and 30 minutes after dosing. The primary objective was to define the pharmacokinetic profile of intraperitoneal chloroprocaine, including in vivo half-life. The secondary objective was to evaluate tolerability through determination of peak plasma concentration and prospective assessment for local anesthetic systemic toxicity. Results: The peak plasma concentration occurred 5 minutes after intraperitoneal administration in all 3 cohorts: 64.8 ng/mL (6.5 µg/kg), 28.7 ng/mL (2.9 µg/kg), and 799.2 ng/mL (79.9 µg/kg) for 1%, 2%, and 3% chloroprocaine, respectively. The in vivo half-life of chloroprocaine after intraperitoneal administration was estimated to be 5.3 minutes (95% confidence interval, 4.0-6.6). We did not detect clinical signs of local anesthetic systemic toxicity in any of the 3 cohorts. Conclusions: The in vivo half-life of intraperitoneal chloroprocaine (5.3 minutes) is more than an order of magnitude greater than the in vitro half-life (11-21 seconds). However, maximum plasma concentrations of chloroprocaine (Cmax range, 0.05-79.9 µg/kg) were not associated with local anesthetic systemic toxicity and remain well below our predefined safe level of exposure (970 µg/kg) and levels associated with clinical symptoms (2.6-2.9 mg/kg). Therefore, our study suggests that intraperitoneal chloroprocaine, in a dosage ≤1200 mg, administered after fetal extraction, is well tolerated during cesarean delivery.
Article
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Surgery during pregnancy is complicated by the need to balance the requirements of two patients. Under usual circumstances, surgery is only conducted during pregnancy when it is absolutely necessary for the wellbeing of the mother, fetus, or both. Even so, the outcome is generally favourable for both the mother and the fetus. All general anaesthetic drugs cross the placenta and there is no optimal general anaesthetic technique. Neither is there convincing evidence that any particular anaesthetic drug is toxic in humans. There is weak evidence that nitrous oxide should be avoided in early pregnancy due to a potential association with pregnancy loss with high exposure. There is evidence in animal models that many general anaesthetic techniques cause inappropriate neuronal apoptosis and behavioural deficits in later life. It is not known whether these considerations affect the human fetus but studies are underway. Given the general considerations of avoiding fetal exposure to unnecessary medication and potential protection of the maternal airway, regional anaesthesia is usually preferred in pregnancy when it is practical for the medical and surgical condition. When surgery is indicated during pregnancy maintenance of maternal oxygenation, perfusion and homeostasis with the least extensive anaesthetic that is practical will assure the best outcome for the fetus.
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With the advent of minimally invasive gastric surgery, visceral nociception has become an important area of investigation as a potential cause of postoperative pain. A systematic review and meta-analysis was carried out to investigate the clinical effects of intraperitoneal local anaesthetic (IPLA) in laparoscopic gastric procedures. Comprehensive searches were conducted independently without language restriction. Studies were identified from the following databases from inception to February 2010: Cochrane Central Register of Controlled Trials, the Cochrane Library, MEDLINE, PubMed, Embase and CINAHL. Relevant meeting abstracts and reference lists were searched manually. Appropriate methodology according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was adhered to. Five randomized controlled trials in laparoscopic gastric procedures were identified for review. There was no significant heterogeneity between the trials (χ(2) = 10·27, 10 d.f., P = 0·42, I(2) = 3 per cent). Based on meta-analysis of trials, there appeared to be reduced abdominal pain intensity (overall mean difference in pain score -1·64, 95 per cent confidence interval (c.i.) -2·09 to -1·19; P < 0·001), incidence of shoulder tip pain (overall odds ratio 0·15, 95 per cent c.i. 0·05 to 0·44; P < 0·001) and opioid use (overall mean difference -3·23, -4·81 to -1·66; P < 0·001). There is evidence in favour of IPLA in laparoscopic gastric procedures for reduction of abdominal pain intensity, incidence of shoulder pain and postoperative opioid consumption.
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There is a lack of cohesive reports on the systemic levels of local anaesthetic after intraperitoneal application. A comprehensive systematic review with no language restriction was conducted. Eighteen suitable articles were identified. Data were compiled and presented according to local anaesthetic agent. Intraperitoneal local anaesthetic has been studied in many different procedures, including open and laparoscopic surgery. A total of 415 patients were included for analysis. There were no cases of clinical toxicity. There were 11 (2.7%) cases with a systemic level above or close to a safe threshold (as determined by the report authors) in three trials utilising intraperitoneal local anaesthetic after laparoscopic cholecystectomy. Intraperitoneal lignocaine doses varied from 100 to 1000 mg, mean Cmax ranged from 1.01 to 4.32 microg/ml and mean Tmax ranged from 15 to 40 minutes. Intraperitoneal bupivacaine doses varied from 50 to 150 mg (weight based doses also reported), mean Cmax ranged from 0.29 to 1.14 microg/ml and mean Tmax ranged from 15 to 60 minutes. Intraperitoneal ropivacaine doses varied from 100 to 300 mg, mean Cmax ranged from 0.66 to 3.76 microg/ml and mean Tmax ranged from 15 to 35 minutes. The addition of adrenaline to intraperitoneal local anaesthetic almost halves systemic levels and prolongs Tmax. Intraperitoneal local anaesthetic results in detectable systemic levels in the perioperative setting. Despite a lack of clinical toxicity, careful attention to dose is still required to prevent potential systemic toxic levels. Clinicians should also consider the addition of adrenaline to intraperitoneal local anaesthetic solutions to further add to the systemic safety profile.
Article
Background: Cesarean delivery is a commonly performed procedure worldwide. Despite improvements in balanced multimodal analgesia, there remains a proportion of women for whom postoperative pain relief and patient satisfaction are still inadequate. Intraperitoneal instillation of local anesthetic has been shown to be effective in reducing postoperative pain after abdominal surgery. We sought to investigate the effect of intraperitoneal instillation of lidocaine on postcesarean delivery pain as part of a multimodal analgesia regimen. Methods: We studied women scheduled for elective cesarean delivery under spinal anesthesia. Spinal anesthesia was performed with 0.75% hyperbaric bupivacaine, fentanyl, and morphine. At the end of the cesarean delivery, immediately before parietal peritoneum or fascia closure, patients were randomized to receive either lidocaine (20 mL 2% lidocaine with epinephrine) or placebo (20 mL normal saline) instilled into the peritoneal cavity. The primary outcome was pain score on movement at 24 hours. Secondary outcomes were pain score at rest and on movement at 2, 24, and 48 hours; maternal satisfaction score; analgesic consumption; incidence of nausea, vomiting, and itching; and return of bowel function. Results: Two hundred four women were recruited. Baseline characteristics were similar between the lidocaine and placebo groups. Pain scores at 24 hours postcesarean delivery on movement (parameter estimate 0.02 [95% confidence interval {CI} -0.14 to 0.18]; P = .823) and at rest (parameter estimate 0.00 [95% CI -0.32 to 0.33]; P = .986) were similar in both groups. Pain scores at 2 hours postcesarean delivery on movement (parameter estimate -0.58 [95% CI -0.90 to -0.26]; P = .001) and at rest (parameter estimate -1.00 [95% CI -1.57 to -0.43]; P = .001) were lower in the lidocaine group. Subgroup analysis of patients with peritoneum closure revealed significantly lower pain scores at 24 hours on movement (parameter estimate -0.33 [95% CI -0.64 to -0.03]; P = .032) in the lidocaine group. The number of women requesting postoperative opioids for breakthrough pain was significantly lower in the lidocaine group compared with that of the placebo (40 [40%] vs 61 [65%], respectively, relative risk 0.59 [95% CI 0.43-0.81]; P = 0.001). Conclusions: The use of intraperitoneal instillation of lidocaine improves early postoperative pain management after cesarean delivery. Furthermore, it reduces the number of women requesting systemic opioids in the immediate postpartum period. Women undergoing peritoneal closure may particularly benefit from this intervention.
Article
In a retrospective survey, we found 1% cases with complete and partial failure of spinal anesthesia for cesarean delivery between 2008 and 2010, which we attributed to underreporting because of the study design. In this prospective study, we determined the incidence of failed spinal anesthesia and identified the factors that increased its risk. This prospective, observational study consisted of all spinal anesthetics administered for cesarean delivery surgery from January 2011 to December 2013. Our definition of failure covered complete (preoperative) failure to achieve a pain-free operative condition and pain during surgery (intraoperative failure). Of a total of 3568 cesarean deliveries, there were 3239 (90.8%) spinal blocks, and the overall failure was 294 (9.1%). These were rescued by conversion to general anesthesia (22.8%) and repeating spinal (23.1%) and IV analgesic supplementation (54.1%). Analysis by logistic regression model indicated that factors associated with failure were the level of experience of the anesthesia provider as shown by senior registrar (adjusted risk ratio [RR], 1.4; 95% confidence interval [CI], 1.0-1.9), >1 lumbar puncture attempt (adjusted RR, 1.5; 95% CI, 1.1-1.9), and use of the L4/L5 interspace (adjusted RR, 1.7; 95% CI, 1.4-2.0). The rate of failed spinal anesthesia from this study was high. The independent predictors of failure were multiple lumbar puncture attempts, use of the L4/L5 interspace, and the level of experience of the anesthesia provider. It is imperative to develop clear guidelines to standardize our obstetric spinal anesthetic practice as well as the management of failures.
Article
To investigate risk factors predicting unplanned conversion to general anesthesia during elective cesarean section, and to examine maternal and fetal outcomes associated with unplanned conversion compared with other modes of anesthesia. A retrospective cohort at a UK center (2008 to 2013). Women (4337) underwent elective cesarean section. Delivery outcomes were compared according to anesthesia type using logistic regression. Women (1.6%) underwent unplanned conversion to general anesthetic. Unplanned conversion was associated with higher parity (odds ratio (OR) 3.82, confidence interval (CI; (1.58 to 9.62)) and maternal age ⩾40 (OR 4.40, CI (1.08 to 29.88)). Compared with spinal anesthetic, unplanned conversion was associated with increased likelihood of maternal hemorrhage ⩾1.5 l (OR 5.74, CI (1.90 to 14.01)) and delayed neonatal respiration (OR 4.76, CI (1.76 to 11.05)). Adverse outcomes were not significantly more likely compared with planned general anesthetic. Higher parity and maternal age are risk factors for unplanned conversion to general anesthetic. There is no increase in the likelihood of adverse outcomes with unplanned versus planned general anesthetic.Journal of Perinatology advance online publication, 11 June 2015; doi:10.1038/jp.2015.62.
Article
It remains unclear whether analgesia from intraperitoneal local anesthetics is via local or central mechanisms. This double-blind clinical trial tests the hypothesis that intraperitoneal local anesthetic is superior to continuous IV infusion for pain management. Primary outcome was morphine consumption during 0 to 24 h. Informed consent was obtained from 60 patients, age 30 to 75 yr, American Society of Anesthesiologists physical status I to II, undergoing abdominal hysterectomy. A computer-generated program randomized patients in parallel arms to group IV: continuous infusion of lidocaine 50 mg/h (10 ml) IV and saline 10 ml/h intermittently intraperitoneal; group IP: injection of lidocaine 50 mg/h (10 ml) once every hour intraperitoneally and continuous infusion of saline 10 ml/h intravenously; and group P (placebo): saline 10 ml/h both intravenously and intermittent intraperitoneal injection. Postoperative morphine consumption, pain intensity, recovery, home discharge, and lidocaine concentrations were measured. Morphine consumption during 0 to 24 h was lower in group IP versus group IV, mean difference -22.6 mg (95% CI, 11.4 to 33.8; P < 0.01). No difference was seen between group IV and group P. The total mean plasma concentration of lidocaine in group IP was significantly lower than group IV, 0 to 4.5 h postoperatively (P = 0.03) with no evidence of systemic toxicity. Pain intensity and other recovery parameters were similar between the groups. The lower supplemental morphine consumption and plasma lidocaine concentration in group IP would confirm that the effects of local anesthetics are likely to be predominant via local intraperitoneal receptors or anti-inflammatory effects and not via central mechanisms alone.
Article
Study objective: To evaluate the effect on postoperative pain of intraperitoneal instillation of dilute bupivacaine at the conclusion of laparoscopic hysterectomy. Design: Prospective, randomized, double-blind, placebo-controlled trial (Canadian Task Force classification I). Setting: Tertiary care, urban, academic teaching hospital. Patients: Women aged 18 to 65 years undergoing total or supracervical laparoscopic hysterectomy with or without salpingo-oophorectomy. Intervention: Randomization to intraperitoneal instillation of bupivacaine vs normal saline solution at the conclusion of laparoscopic hysterectomy performed because of benign indications. Measurements and main results: A total of 160 patients consented to participate in the study and were randomized to receive either intraperitoneal instillation of 100 mg bupivacaine in 100 mL normal saline solution or 100 mL normal saline solution alone, at the conclusion of laparoscopic hysterectomy. Sixty seven of 77 patients (87%) in the treatment group and 73 of 80 patients (91%) in the placebo group completed the study. There were no significant differences in demographic profile, indication for hysterectomy, or number of previous surgeries between the two groups. All patients were prescribed a standardized routine postoperative analgesic regimen. Pain was measured by patient self-report using a 10-cm visual analog scale (VAS) at 1, 2, 4, 6, 12, and 24 hours postoperatively. Mean VAS scores at all time points were between 2.0 and 4.3 and were highest in the first postoperative hour. VAS scores were not significantly different between the two groups at any time point. None of the measured secondary outcomes were significantly different between the bupivacaine and placebo groups, including total postoperative opioid analgesic use in morphine equivalents (23.2 mg vs 27.5 mg; p = .09), length of hospital stay in hours (23.3 vs 23.0; p = .49), patient satisfaction on a 10-cm VAS (9.0 vs 8.2; p = .12), and complication rates (9% vs 15%; p = .35). Conclusion: Intraperitoneal instillation of bupivacaine at the conclusion of laparoscopic hysterectomy does not reduce postoperative pain. Opioid analgesic use, length of hospital stay, overall patient satisfaction, and complication rates are also unchanged. Self-reported postoperative pain was low in both groups after this major gynecologic surgery performed laparoscopically.
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The incidence of cesarean delivery (CD), which is defined as the birth of a fetus through incisions in the abdomen (laparotomy) and uterus (hysterotomy), has undergone progressive increases and currently accounts for 15% to 30% of all deliveries in developed countries worldwide. Indications The common indications for CD include previous CD, cephalopelvic disproportion, dystocia, fetal malpresentation, placenta previa or abruptio placentae, prematurity, non-reassuring fetal status, and patient request. A prior CD does not require subsequent pregnancies to be delivered in this manner, although a trial of labor after CD (TOLAC; which, if successful, is referred to as a vaginal birth after CD [VBAC]) is an alternative, albeit declining, option.
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This systematic review and meta-analysis evaluates evidence for seven risk factors associated with failed conversion of labor epidural analgesia to cesarean delivery anesthesia. Online scientific literature databases were searched using a strategy which identified observational trials, published between January 1979 and May 2011, which evaluated risk factors for failed conversion of epidural analgesia to anesthesia or documented a failure rate resulting in general anesthesia. 1450 trials were screened, and 13 trials were included for review (n=8628). Three factors increase the risk for failed conversion: an increasing number of clinician-administered boluses during labor (OR=3.2, 95% CI 1.8-5.5), greater urgency for cesarean delivery (OR=40.4, 95% CI 8.8-186), and a non-obstetric anesthesiologist providing care (OR=4.6, 95% CI 1.8-11.5). Insufficient evidence is available to support combined spinal-epidural versus standard epidural techniques, duration of epidural analgesia, cervical dilation at the time of epidural placement, and body mass index or weight as risk factors for failed epidural conversion. The risk of failed conversion of labor epidural analgesia to anesthesia is increased with an increasing number of boluses administered during labor, an enhanced urgency for cesarean delivery, and care being provided by a non-obstetric anesthesiologist. Further high-quality studies are needed to evaluate the many potential risk factors associated with failed conversion of labor epidural analgesia to anesthesia for cesarean delivery.
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We reviewed the effectiveness of intraperitoneal instillation of local anesthetic on pain after gynecologic laparoscopic surgery. Sources included the Cochrane Central Register of Controlled Trials, MEDLINE/PubMed, EMBASE, and Ovid MEDLINE In-Process & Other Non-Indexed Citations databases, and abstracts, reference lists, and randomized controlled trial (RCT) registries. The 7 included RCTs compared pain scores after administration of intraperitoneal analgesics or placebo/control during gynecologic laparoscopic surgery with benign indications. Outcome measures were pain scores (per visual analog scale) at 1 to 2, 4 to 6, and 24 hours postoperatively. Pain scores were significantly lower in the groups receiving local anesthesia at 1 to 2 hours (weighted mean difference [WMD], -1.82; 95% confidence interval [CI], -2.55 to -1.08]) and 4 to 6 hours postoperatively (WMD, -2.00; 95% CI, -3.64 to -0.35), but were similar at 24 hours (WMD, -1.43; 95% CI, -1.15 to 0.96). Local analgesia instilled intraperitoneally significantly decreased pain during a 6-hour interval after gynecologic laparoscopy.
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Birth by emergency caesarean section (CS) is common and often considered urgent (category 1). In the UK, over half of all category 1 CS are performed under general anaesthesia (GA). In this setting, little is known about the effect of the mode of anaesthesia on the neonate. A retrospective cohort study was performed using routinely collected de-identified data from Mater Health Services, Brisbane, Australia. The data set included 533 term babies born by category 1 CS for presumed fetal compromise between 2008 and 2011. Bivariate and multivariate analyses were undertaken. The outcomes of 81 babies born by GA CS were compared with 452 by CS under regional anaesthesia (RA). Compared with a category 1 CS under RA, the decision-to-delivery interval for a GA CS was almost eight minutes faster (24.7 vs 32.6 minutes; P < 0.001). When adjusted for confounders, babies born by category 1 GA CS were significantly more likely to have an Apgar score < 7 at five minutes (aOR 6.89; 95%CI 1.79-26.55; P = 0.005), to require Neopuff or bag/mask ventilation for > 60 seconds (aOR 2.34; 95%CI 1.13-4.84; P = 0.022) and to be admitted to a neonatal intensive care nursery (aOR 2.24; 95%CI 1.16-4.31; P = 0.016). General anaesthesia was associated with short-term neonatal morbidity of term babies born by category 1 CS for presumed fetal compromise, despite enabling a more rapid delivery of the baby. These data should help inform the discussion between anaesthetist and obstetrician, in balancing the risks and benefits of the mode of anaesthesia.
Article
To evaluate the effects of intraperitoneal instillation of lidocaine on postcesarean pain in patients with pariental periotoneal closure. A sample of 370 pregnant women, presenting early in labor, with no history of abdominal surgery and with indications for cesarean section were operated on with closure of the parietal peritoneum. They randomly received either 200 mg of intraperitoneal lidocaine or sterile saline (0.9%). Pain scores on the first and fifteenth postoperative days were recorded and followed up every 2 weeks up to 8 months after surgery. Overall incidence and pain scores of epigastric and global abdominal pain were more frequent in the controls than in the lidocaine group. The incidence of persistent postcesarean pain after 8 months dropped from 20.8.0% to 10.8% (P<0.001) when intraperitoneal lidocaine was instilled. Intraperitoneal instillation of 200 mg of lidocaine decreased the incidence and scores of postcesarean pain when the parietal peritoneum was sutured. Further studies in a setting offering more effective acute pain control protocols, preferably with patient-controlled analgesia, are recommended to assess the use of lidocaine before it can be widely practiced.
Article
Obstetrics carries high medical liability risk. Maternal death and newborn death/brain damage were the most common complications in obstetric anesthesia malpractice claims before 1990. As the liability profile may have changed over the past two decades, the authors reviewed recent obstetric claims in the American Society of Anesthesiologists Closed Claims database. Obstetric anesthesia claims for injuries from 1990 to 2003 (1990 or later claims; n = 426) were compared to obstetric claims for injuries before 1990 (n = 190). Chi-square and z tests compared categorical variables; payment amounts were compared using the Kolmogorov-Smirnov test. Compared to pre-1990 obstetric claims, the proportion of maternal death (P = 0.002) and newborn death/brain damage (P = 0.048) decreased, whereas maternal nerve injury (P < 0.001) and maternal back pain (P = 0.012) increased in 1990 or later claims. In 1990 or later claims, payment was made on behalf of the anesthesiologist in only 21% of newborn death/brain damage claims compared to 60% of maternal death/brain damage claims (P < 0.001). These payments in both groups were associated with an anesthesia contribution to the injury (P < 0.001) and substandard anesthesia care (P < 0.001). Anesthesia-related newborn death/brain damage claims had an increased proportion of delays in anesthetic care (P = 0.001) and poor communication (P = 0.007) compared to claims unrelated to anesthesia. Newborn death/brain damage has decreased, yet it remains a leading cause of obstetric anesthesia malpractice claims over time. Potentially preventable anesthetic causes of newborn injury included delays in anesthesia care and poor communication between the obstetrician and anesthesiologist.
Article
A review was made of histories of 5010 patients delivered by the senior author over a period of 25 years. Of these deliveries, cesarean section was performed in 283 (5.6%). In 218 of these patients, only local field block of the abdominal wall was done prior to the birth of the baby. When local anesthesia was used, 92% of newborn babies cried spontaneously at once, There were 48 premature babies and 7 neonatal deaths, the latter caused primarily by pregnancy complications and secondarily by prematurity. Fetuses already at high risk are most benefited by the use of local anesthesia prior to birth. Many of the patients experiencing this method had second, third, and even fourth cesarean sections with the use of local anesthesia.
Article
Malpractice claims filed against anesthesiologists for care involving obstetric (OB) anesthesia (n = 190) were taken from the American Society of Anesthesiologists' Closed Claims Database and compared to claims not involving OB cases (n = 1351). The most common complications in the OB claims were (percentage of all OB claims): maternal death (22%), newborn brain damage (20%), and headache (12%). In contrast, the most common complications in the nonobstetric (non-OB) group were (percentage of all non-OB claims): death (39%), nerve damage (16%), and brain damage (13%). The group of OB claims contained a proportionately greater number of minor injuries, such as headache, backache, pain during anesthesia, and emotional injury (32%) compared to the non-OB claims (4%). Complications due to aspiration and convulsions were more common among the OB cases. The standard of care was judged to have been met in 46% of OB and 39% of non-OB claims. This difference is not statistically significant. Claims involving general anesthesia were more frequently associated with severe injuries and resulted in higher payments than did claims involving regional anesthesia. Payments were made in a similar proportion of OB and non-OB claims (53 and 59%, respectively). For cases in which payments were made, the median payment for OB claims was significantly greater ($203,000) than for non-OB claims ($85,000; P less than or equal to 0.05).
Article
The aims of this study were to assess the analgesic effect of the intraperitoneal topical administration of 0.375% bupivacaine in patients undergoing laparoscopic cholecystectomy and to carry out a pharmacokinetic study of bupivacaine administered topically by intraperitoneal route. Randomized, double-blind controlled trial. Twenty-four patients of ASA physical status 1 or 2, undergoing elective laparoscopic cholecystectomy, were included. Anaesthesia technique was the same for all patients. At the end of surgery, they were randomly assigned to one of two groups. Patients in group bupivacaine were administered 0.375% bupivacaine, 0.6 mL.kg-1 intraperitoneally in both subdiaphragmatic areas and the cholecystectomy wound, those of the control group were given the same volume of NaCl 0.9%. Analgesia was provided by morphine PCA. Postoperative pain, assessed on a 100 mm visual analogue pain scale (VAS), and administered morphine were recorded 30 min after extubation, and 0.5, 1, 2, 3, 6, 12, 24, 36 and 48 hours later. Blood samples were collected 2, 5, 15, 30, 60, 90, 120, 180, 300 and 480 min after the intraperitoneal administration of bupivacaine to measure bupivacaine plasma concentration. Statistics included Student t test and Chi square test. P < 0.05 was considered significant. There was no significant difference between the two groups with regard to VAS scores during the first 48 postoperative hours. Morphine requirements (total and at each point) were also similar. Plasma bupivacaine concentrations reached a plateau at 10-20 min, and then decreased slowly. The median plasma peak concentration was 0.94 +/- 0.47 microgram.mL-1. In one patient toxic concentrations (> 1.6 micrograms.mL-1) during the first 60 min after intraperitoneal administration were obtained, while in another patient a concentration of 1.58 micrograms.mL-1 was reached twice. Intraperitoneal administration of 0.6 mL.kg-1 of 0.375% bupivacaine is ineffective in reducing postoperative pain after laparoscopic cholecystectomy. Furthermore these high doses of bupivacaine may result in toxic plasma concentrations. This technique is not safe and cannot be recommended.
Article
Unlabelled: We conducted a randomized, double-blinded, placebo-controlled trial to evaluate the effectiveness of intraperitoneal lidocaine, IM morphine, or both drugs together for pain relief in postpartum tubal ligation. Eighty postpartum patients scheduled to have tubal sterilization were randomly divided into four groups to receive IM isotonic sodium chloride solution (1 mL) and intraperitoneal instillation of 80 mL of isotonic sodium chloride solution (Group P); IM morphine (10 mg in 1 mL) and intraperitoneal instillation of 80 mL of isotonic sodium chloride solution (Group M); IM injection of isotonic sodium chloride solution and intraperitoneal instillation of 0.5% lidocaine in 80 mL (Group L); and both IM morphine and intraperitoneal lidocaine instillation (Group ML). The minilaparotomy was performed after local infiltration with 15 mL of 1% lidocaine. A numerical rating score was used to rate pain on a 0-10 scale during the surgical procedures. The mean pain scores were 1.2 in Group L and 0.8 in Group ML. These pain scores were significantly lower than those in Groups P and M, which were 5.5 and 6.0, respectively (P < 0.001). Implications: Pain relief was inadequate in patients undergoing postpartum tubal ligation under local anesthesia, even after the administration of IM morphine. Instilling lidocaine into the abdominal cavity, however, effectively decreased intraoperative pain in these patients.
Article
Visceral pain is the most common form of pain produced by disease and one of the most frequent reasons why patients seek medical attention. Yet much of what we know about the mechanisms of pain derives from experimental studies of somatic not visceral nociception. The conventional view is that visceral pain is simply a variant of somatic pain, a view based on the belief that a single neurological mechanism is responsible for all pain. However, the more we learn about the mechanisms of somatic and visceral pain, the more we realise that although these two processes have much in common, they also have important differences. Although visceral pain is an important part of the normal sensory repertoire of all human beings and a prominent symptom of many clinical conditions, not much clinical research has been done in this field and there are few clinical scientists with expertise in the management of visceral pain. Instead, visceral pain is usually treated by a range of specialists who take quite different approaches to the management of this type of pain. Thus, the management of visceral pain is frequently unsatisfactory. In this review, we consider visceral pain as a separate form of pain and examine its distinct sensory properties from a clinical perspective. We describe recent research findings that may change the way we think about visceral pain and, more importantly, may help develop new procedures for its management.
Article
Maternal Mortality Surveillance has been conducted by the State of Michigan since 1950, and anesthesia-related maternal deaths were most recently reviewed for the years 1972-1984. Records for pregnancy-associated deaths between 1985 and 2003 were reviewed to identify 25 cases associated with a perioperative arrest or major anesthetic complication. Four obstetric anesthesiologists independently classified these cases, and disagreements were resolved by discussion. Precise definitions of anesthesia-related and anesthesia-contributing maternal death were constructed. Anesthesia-related deaths were reviewed to identify the chain of medical errors or care management problems that contributed to each patient death. Of 855 pregnancy-associated deaths, 8 were anesthesia-related and 7 were anesthesia-contributing. There were no deaths during induction of general anesthesia. Five resulted from hypoventilation or airway obstruction during emergence, extubation, or recovery. Lapses in either postoperative monitoring or anesthesiology supervision seemed to contribute to 5 of the 8 anesthesia-related deaths. Other characteristics common to these cases included obesity (n=6) and African-American race (n=6). The 8 anesthesia-related and seven anesthesia-contributing maternal deaths in Michigan between 1985 and 2003 illustrate three key points. First, all anesthesia-related deaths from airway obstruction or hypoventilation took place during emergence and recovery, not during the induction of general anesthesia. Second, system errors played a role in the majority of cases. Of concern, lapses in postoperative monitoring and inadequate supervision by an anesthesiologist seemed to contribute to more than half of the deaths. Finally, this report confirms previous work that obesity and African-American race are important risk factors for anesthesia-related maternal mortality.
Article
To determine whether ropivacaine infiltration into all layers of the abdominal cesarean wound and spraying of the peritoneum decreases postoperative pain. A randomized controlled trial of women undergoing cesarean delivery under general anesthetic allocated to receive either 30 mL of 0.75% ropivacaine or 30 mL of saline into the wound, including spraying of the peritoneum. Postoperative pain and need for rescue opioids were assessed. Of the 50 women in the ropivacaine group, 24 (48%) required pethidine or experienced severe pain within 1 hour postoperatively compared with 47 (94%) of 50 women in the control group (relative risk 0.51, 95% CI, 0.38-0.69). The amount of pethidine used in the first hour was reduced in the ropivacaine group (mean difference -58, 95% CI, -73.53 to -42.40). Use of diclofenac and tramadol/paracetamol was also reduced in the ropivacaine group. Ropivacaine wound infiltration and peritoneal spraying during cesarean delivery under general anesthetic reduces severe pain and need for opioids.
Regional block versus general anaesthesia for caesarean section and neonatal outcomes: a population-based study.
  • C S Algert
  • J R Bowen
  • W B Giles
  • G E Knoblance
  • S J Lain
  • C L Roberts