Anaesthesia
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Randomized Controlled Trial Comparative Study
Epidural lidocaine-bicarbonate-adrenaline vs levobupivacaine for emergency Caesarean section: a randomised controlled trial.
Epidural mixtures containing lidocaine with or without additives are commonly used to convert epidural analgesia in labour to anaesthesia for emergency Caesarean section, but direct comparisons with alternative, single agents in this situation are few. In a prospective double-blinded trial, we compared a freshly prepared lidocaine-bicarbonate-adrenaline mixture (final concentrations 1.8%, 0.76% and 1:200,000, respectively) with our standard agent, levobupivacaine 0.5%, for extending epidural blockade for emergency Caesarean section. Using a sequential analysis technique, with data analysed in blocks of 40, women receiving epidural analgesia in labour who required top-up for Caesarean section were randomly assigned to receive 20 ml of epidural solution over 3 min. ⋯ Pre- and intra-operative supplementation/pain, maternal side-effects and neonatal outcomes (excluding five women who underwent instrumental delivery) were similar between the groups. Intra-operative maternal sedation (scored by the mother on a 10-point scale) was greater with lidocaine-bicarbonate-adrenaline (4.5 (3-8 [1-9])) than with levobupivacaine (3 (1-4 [1-7])), but not significantly so (p = 0.07). We conclude that epidural lidocaine-bicarbonate-adrenaline halves the onset time when extending epidural analgesia for Caesarean section although there is a possibility of increased maternal sedation.
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Hypoxaemia during anaesthetic induction in obstetrics is hazardous for mother and baby, but the onset of desaturation can be delayed by pre-oxygenation. This study investigated pre-oxygenation during pregnancy using computer simulation. The Nottingham Physiology Simulator was configured to replicate normal pregnant physiology. ⋯ Pre-oxygenation during tidal breathing proceeded more rapidly in pregnancy, the median [range] time to achieve 95% of the maximum change in P(E)O2 being 1 min 37 s [1:23-1:52] in pregnant subjects, compared to 2 min 51 s [2:28-3:15] in non-pregnant subjects. Vital capacity pre-oxygenation required seven breaths [5-10] in pregnant subjects, compared to six breaths [4-9] in non-pregnant subjects, to achieve the same P(E)O2 as after 95% complete tidal pre-oxygenation. We recommend 2 min of tidal breathing for pre-oxygenation in pregnancy.
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Editorial Comment
Anaesthetic research in the United Kingdom: publishing or perishing?