Anaesthesia
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Randomized Controlled Trial
The effect of spinal hyperbaric bupivacaine-fentanyl or hyperbaric bupivacaine on uterine tone and fetal heart rate in labouring women: a randomised controlled study.
The mechanism for fetal heart rate abnormalities following spinal opioids remains controversial. We evaluated uterine tone, using an intra-uterine pressure catheter, and fetal heart rate abnormalities in 30 women in spontaneous labour with cervical dilation of 3-5 cm having combined spinal-epidural analgesia. Women were randomly assigned to receive a spinal with 2.0 mg hyperbaric bupivacaine plus 15 μg fentanyl, or 2.5 mg hyperbaric bupivacaine. ⋯ Seven (47%) in the bupivacaine-fentanyl group showed new onset fetal heart rate changes during the 30-min period after the spinal, compared with two (13%) in the bupivacaine group (p = 0.04); however, these were transient and responded to intra-uterine resuscitation. Pain scores, sensory and motor block as well as neonatal outcomes were comparable between the groups. We found that raised baseline uterine tone was not more frequent when using bupivacaine-fentanyl rather than bupivacaine in the spinal component of combined spinal-epidural, although absolute values of baseline tone were higher, and fetal heart rate changes more frequent, in the former group.
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Postoperative hospital stay is longer for frail, older patients, who are more likely to experience prolonged postoperative morbidity and reduced long-term survival. We recorded in-hospital mortality, morbidity and length of stay for 164 patients aged at least 65 years after unscheduled surgery. We evaluated pre-operative frailty with the 7-point Clinical Frailty Scale: 81 patients were 'not vulnerable' (frailty score 1-3) and 83 were 'vulnerable or frail' (frailty score ≧ 4), with mean (SD) ages of 74.7 (7.5) years vs. 79.4 (8.3) years, respectively, p < 0.001. ⋯ Postoperative morbidity was less frequent in patients categorised as 'not vulnerable' on four out of the six days it was measured (days 3, 5, 8, 14, 23, 28). Median (IQR [range]) postoperative stay was 9 (6-18 [2-221]) days for patients with frailty scores 1-3, and 22 (12-33 [2-270]) days for patients with score ≧ 4, p < 0.001. Four variables independently associated with hospital discharge, hazard ratio (95%CI): E-POSSUM, 0.74 (0.60-0.92), p = 0.007; ASA 2, 0.35 (0.13-0.98), p = 0.046, ASA 3, 0.17 (0.06-0.47), p = 0.001 and ASA 4/5, 0.08 (0.02-0.28), p < 0.001; operative severity 'major +', 0.69 (0.41-1.08), p = 0.10 and the Surgical Outcome Risk Tool, 7.75 (0.81-74.40), p = 0.08.