Abstracts of free papers presented to the combined …...Abstracts of free papers presented to the...

Abstracts of free papers presented to the combined OAA/CARO meetingin Versailles, France on 16-17 April, 2004

ORAL PRESENTATIONS

O01 Equivalent dose of ephedrine and phenylephrine in the prevention of post-spinal hypotensionS Saravanan, M Columb, RC Wilson, EJ Watkins, GR Lyons

O02 Comparison of the time to peak pressor effect of phenylephrine and ephedrine during spinal anaesthesia forcaesarean sectionDG Thomas, S Gardner

O03 Intravenous vasopressors can affect rostral spread of spinal anaesthesia in pregnancyDW Cooper, L Jeyaraj, R Hynd, R Thompson, T Meek D Ryall, MS Kokri

O04 Development of a new experimental model to study nociceptive pathways in the fetusS Bresson, V Houfflin Debarge, S Jaillard, S Dalmas, P Deruelle, AS Ducloy, F Puech, L Storme

O05 Nociceptive stimuli alter the perinatal pulmonary circulationA Delelis, V Houfflin-Debarge, B Larrue, S Jaillard, N Rouaix-Emery, L Storme, S Dalmas, AS Ducloy

O06 Provision of epidural analgesia in labour by non-physicians: a pilot studyT McCarrick, J Curran, D Bogod, L Harrington, C McCormick, P Shuttleworth

O07 Errors and omissions in anaesthesia: a pilot study using a pilot’s checklistE Hart, H Owen, A May

O08 Intravenous versus oral iron therapy for postpartum anaemiaN. Bhandal, R. Russell

O09 Deprivation category and anaesthetic intervention in the obstetric populationKN Litchfield, MG Booth, SJ Young

O10 Suprasternal Doppler estimation of cardiac output following intravenous fluid preloading for caesareansection under spinal anaesthesiaT Selvan, R Fernando, J Bray, M Sodhi, M Columb

O11 Minimum effective dose of intrathecal levobupivacaine and ropivacaine for caesarean sectionR Parpaglioni, MG Frigo, A Lemma, M Sebastiani, G Barbati, D Celleno

O12 Sevoflurane vs Entonox during labour contractionsS Yeo, M Good, C Brennan, SM Yentis, A Holdcroft

O13 Nalmefene for opioid-induced pruritus in laborC Grubb, P Balestrieri, S Prakalapakorn, H McAnally

O14 Comparison of measured and estimated angles of operating table tilt among varying grades of anaesthetistsA Swami, P Sharpe, TM Bourne

O15 Use of Semmes-Weinstein monofilaments for testing spinal anaesthetic block level for caesarean sectionGA Vickers, G Yuill, R Clark, T Ramsay

O16 How long should you have to wait? An audit of transfers from a low risk to a high risk hospital birth centreN Bolad, D Hart, J Wolfe-Barry, G O’Sullivan

O17 Antenatal assessment of high risk pregnancy: A survey of UK practiceM Rai, S Lua, R Russell, M Popat

O18 Epidural analgesia for parturients with type I von Willebrand diseaseD Marrache, FJ Mercier, C Boyer-Neumann, D Meyer, D Benhamou

O19 The EXIT procedure – two case reportsD Shetty, A Gunatilleke, A Relwani, J Clarke

O20 Analgesia for labour in the region of Paris (Ile de France)P Abecassis, FJ Mercier, D Benhamou

O21 Asepsis for neuraxial analgesia in labour: a survey in the region of Paris (Ile de France)P Abecassis, FJ Mercier, D Benhamou

O22 Determining the density of levobupivacaine and ropivacaine at 37°M Camorcia, G Capogna

O23 Audiometric changes after post dural puncture headache and epidural blood patchE Powel, S Gowrie-Mohan, C Fortescue, R Rajamanicam

O24 A survey of the management of accidental dural puncture and post dural puncture headache in UK obstetricpracticeR. Baraz, R.E.Collis

O25 Is maternal preparation for emergency obstetric anaesthesia adequate?C Fortescue, MYK Wee, SM Yentis, S Malhotra, A Holdcroft

International Journal of Obstetric Anesthesia (2004) 13, S1-40doi:10.1016/j.ijoa 2004.03.006

International Journal of Obstetric AnesthesiaS2

O26 Spinal levobupivacaine for cesarean section causes less hypotension and motor block than racemicbupivacaineHC Coppejans, MP Vercauteren

O27 The analgesic efficacy of regional levobupivacaine compared to epidural analgesia after caesarean deliveryP Ranta, J Kukkonen, N Rawal, P Ohtonen, T Raudaskoski, T Ala-Kokko

O28 Dose-finding comparison of spinal levobupivacaine and bupivacaine for caesarean sectionK Khaw, WD Ngan Kee, F Ng, P Leung

O29 Randomised double-blind controlled trial of ropivacaine vs bupivacaine for extending low-dose epiduralanalgesia for emergency caesarean sectionRD Sanders, S Mallory, DN Lucas, TML Chan, S Yeo, SM Yentis

O30 Effect of anaesthesia for caesarean section on neonatal acid-base statusF Reynolds, P Seed, LL Pay

O31 Comparison of maternal haemodynamic effects and respiratory indices during remifentanil and nitrousoxide labour analgesiaP Volmanen, E Akural, T Raudaskoski, S Alahuhta

POSTERS

P01 Post cesarean section analgesia with continuous local infusion of ropivacaine or diclofenacC Marbaix, F Roelants, V Mercier, H Waterloos, D Lacrosse, P Lavand’homme

P02 Continuous wound irrigation with ropivacaine or diclofenac after cesarean section: immediate and delayedbenefitsD Lacrosse, F Roelants, V Mercier, H Waterloos, P Lavand’homme

P03 Dose-response study of epidural neostigmine combined with clonidine in early laborE Malin, F Roelants, V Mercier, P Lavand’homme

P04 Efficacy of epidural neostigmine combined with sufentanil or clonidine to initiate labor analgesiaM Malisse, F Roelants, V Mercier, P Lavand’homme

P05 Combined spinal-epidural analgesia for labour and the effect of epidural volume extensionV Pandit, P Sajith, S Chitre, J Crowhurst, GM Stocks

P06 Patient-controlled epidural analgesia (PCEA) during labor: a comparison of basal ratesC Grubb, P Balestrieri, C Lin, P Ting

P07 Patient controlled intravenous alfentanil administration during elective caesarean section undersubarachnoid anaesthesia: effects of intrathecal fentanyl on analgesic requirementsKN Litchfield, NL Purdie, GNC Kenny, EM McGrady

P08 Sufentanil 5 µg and clonidine 75 µg have a similar effect on the MLAC of ropivacaine in labourJP Galeazzi, N Janssens, J-C Thiry, V Bonhomme, PY Dewandre, P Hans, JF Brichant

P09 The International Journal of Obstetric Anesthesia – oft cited yet not indexedR Davies, SM Yentis and R Wentz

P10 The morbidly obese parturient – anaesthetic management and maternal and fetal outcomesD Mullhi, G Kelly, U Dandekar, N Osborn

P11 Obesity, pregnancy and anaesthesia in a district general hospitalM Rupasinghe, L McLoughlin

P12 Is routine use of combined spinal epidural anaesthesia for all caesarean sections justified?N Walton, S Nikolic, R Sashidharan

P13 Improving the efficiency of elective caesarean section operating listsJ Bell, H Wise, M Wee

P14 Regional anaesthesia for caesarean section: communication of risk and patient satisfactionDA Varveris, A MacFarlane, NG Smart

P15 The use of sodium citrate for acid aspiration prophylaxis in elective caesarean sectionM K Doddi, B H Heidemann

P16 Haematocrit as a predictor of arterial hypotension during spinal anaesthesia in preeclamptic parturientsEM Shifman, GV Filippovitch

P17 National survey of anaesthetic obstetric trainee rotasE Kam, F Dodd

P18 Acceptability of an epidural information cardNA Barrett, HR Jones, A. Kalbag, SM Yentis, J Durbridge, M Cox, MYK Wee

P19 Potential for parenteral drug errors on the labour wardR Hignett, SM Yentis, G O’Sullivan, PN Robinson, MYK Wee

International Journal of Obstetric Anesthesia S3

P20 The Obstetric Anaesthetists’ Association’s UK registry of high-risk obstetric anaesthesia – final reportD Arawwawala, DP Dob, SM Yentis

P21 Patient satisfaction with post caesarean section analgesiaS Garg, R Kumar

P22 Intrathecal opioid-induced pruritus: audit of current departmental practiceC Guha, D Blacoe, F Bryden

P23 Multidisciplinary approach in the management of pregnant women with multiple sclerosisM Khare, S Francis, A May, E Howarth

P24 An audit of epidural blood patch after accidental dural puncture at the Lister Hospital 1997-2003C Fortescue, S Gowrie-Mohan, L Harihar

P25 Diagnosis and treatment of intrapartum PDPH using a normal saline bolusA Wendling, MA Froelich

P26 Low dose sequential CSE for women with severe cardiac disease undergoing caesarean sectionEL Hamlyn, CA Douglass, GM Stocks, JA Crowhurst

P27 The reliability of pulse oximetry in the presence of painted fingernailsC Guha, KN Litchfield, M McNeil

P28 Influence of different labour methods on nitric oxide and malondealdehyde levelsL Pirbudak, M Çekmen, Ö Balat, N Tahtacı, F Aksoy, MG Ugur, S Celiköz

P29 Patient-controlled epidural analgesia or systemic analgesia alone for pain therapy after caesarean section?L Gurlit, M Moellmann, S Gurlit

P30 Anaesthetic management for caesarean section in a parturient with rigid spine syndromeR Kumar, D Lee, S Sharafudeen, MP Waterstone

P31 Ropivacaine: clinical course of two parturients who received 30 mg intrathecallyS Steen, M Mok, C Wu

P32 Assessing regional anaesthesia before caesarean section: a survey of anaesthetists in Anglia, UKS Brown, H Prinzhausen, JA Pickett

P33 The incidence of spinal anaesthesia for caesarean section in Sierra LeoneA Jalloh, A Kargbo, I Bangura, E Vreede

P34 The case fatality rate of eclampsia during the introduction of magnesium in Sierra LeoneE Vreede

P35 Improving maternal resuscitation through simulated peri-arrest scenariosL Monnery, M Kulkhani, D Halliwell, A McCormick

P36 A prospective observational study of the use of the Proseal laryngeal mask airway for postpartum tuballigationRA Dyer, NR Evans, JJ Skowno, PJ Bennett, MF James

P37 Four-grades score to predict the difficulty of epidural blockM Karraz

P38 The obstetric anaesthetic antenatal assessment clinic: a review of 1000 patientsS Francis, SM Yentis, DP Dob

P39 Changes in obstetric anaesthetic practice and the effect on training anaesthetists in a UK District GeneralHospital 1984-2003JS Sprigge

P40 To eat or not to eat? A survey of UK maternity unit policies regarding oral intake during labourD Hart, A Shennan, G O’Sullivan

P41 Management of inadequate epidural analgesia during labour by obstetric anaesthetists in the Paris regionP Abecassis, FJ Mercier, D Benhamou

P42 Epidural ropivacaine 0.1% and sufentanil 0.6 µg/mL to allow ambulation during labourM. Karraz

P43 Use of low-molecular-weight heparin from the first trimester of pregnancy: a retrospective study of 111consecutive pregnanciesA-S Ducloy-Bouthors, P Deruelle, M Denervaud, E Hachulla, A-S Valat, F Puech, N Trillot, P-Y Hatron, D Subtil


O01 Equivalent dose of ephedrine andphenylephrine in the prevention of post-spinalhypotension

S Saravanan, M Columb, RC Wilson, EJ Watkins,GR LyonsSt James University Hospital, Leeds, UK

Background: Post-spinal hypotension has an incidencein obstetric practice of 80% without preventativetreatment. Comparisons between ephedrine andphenylephrine have suffered from a lack of consensuson dose equivalence.1 We therefore aimed to establishdose equivalence based on clinical criteria betweenephedrine and phenylephrine in the prevention of postspinal hypotension in caesarean section.

Method: 80 mothers with healthy, singleton pregnancyand ASA grade I or II, 150-180 cm tall, 50-120 kgpresenting for elective caesarean section were recruitedinto this prospective, randomised and double-blindsequential allocation study. All received 0.5%hyperbaric bupivacaine 2.6 mL and diamorphine 400µg intrathecally in the sitting position with a combinedspinal-epidural technique. Group A had ephedrine andGroup B phenylephrine in their prophylacticvasopressor infusion, which was started at the end ofintrathecal injection. All were laid flat with left tilt. Thefirst patient in group A received ephedrine 50 mg and ingroup B received phenylephrine 500 µg, in 500 mL ofsaline. All infusions were started at a rate of 999 mL/hthrough a Gemini IMED infusion pump. The primaryoutcome was efficacy in prevention of hypotension(<75% of baseline systolic pressure) and bradycardia(<60) or tachycardia (>130). The dose for subsequentpatients depended on the efficacy of the previouspatient’s dose. If the previous dose was effective, thesubsequent patient’s dose of vasopressor in 500 mLsaline was decreased by 5 mg ephedrine, and 50 µgphenylephrine in their respective groups. If the previousdose was ineffective, the next patient’s dose wasincreased by same amount. Up-down data wereanalysed using Dixon-Massey for ED50/500 mL saline.

Results: ED50 is starting dose in 500 mL salineEC50 is concentration at 1 L/h infusion rate

Ephedrine Phenylephrine

ED50

[95% CI]

EC50

43.25 mg

[34.87-56.62]

86.5 µg/mL

522.9 µg

[474.5-606.3]

1.045 µg/mL

Potency ratio 83 [56-118] 1

Conclusion: Potency ratio of phenylephrine toephedrine in prevention of post-spinal hypotension is83:1 [95%CI 56-118]. Published studies have usedratios varying from 20:1 to 250:1.

Reference1. Lee A, Ngan Kee WD, Gin T. A quantitative, systematic review

of randomized controlled trials of ephedrine versusphenylephrine for the management of hypotension during spinalanesthesia for cesarean delivery. Anesth Analg 2002; 94: 920-926.

O02 Comparison of the time to peak pressor effectof phenylephrine and ephedrine during spinalanaesthesia for caesarean section

DG Thomas, S GardnerUniversity Hospital of North Durham, Durham, UK

Introduction: Hypotension is common during spinalanaesthesia for caesarean section. Ngan Kee et al. notedthat maternal systolic arterial pressure continued to riseafter a reduction in the rate of ephedrine infusion,which they attributed to the indirect action of ephedrineat sympathetic neurones.1 This may also delay the onsetof the pressor effect compared with direct-acting α1-agonists. The aim of this study was to compare the timeto peak pressor effect of phenylephrine and ephedrinewhen used to control maternal arterial pressure duringspinal anaesthesia for caesarean section.

Methods: After ethics committee approval 20 healthywomen with uncomplicated singleton pregnancyscheduled for elective caesarean section consented torecruitment. Maternal arterial pressure was measuredby automated oscillometry before induction of spinalanaesthesia and at one-minute intervals thereafter. Afterinduction of spinal anaesthesia beat-by-beat fingerarterial pressure was measured (Finapres, Ohmeda,UK) and analog pressure waveforms were recorded(Powerlab 8sp and Chart 5, ADInstruments, UK) on anotebook computer. Patients were randomly allocatedto be given either phenylephrine 100 µg (group P) orephedrine 10 mg (group E) intravenously if systolicarterial pressure (SAP), measured by oscillometry, fellto 90% of its baseline value. The oscillometric SAP thatpreceded injection of vasopressor and the followingthree consecutive measurements were recorded. Furthervasopressor was not given unless SAP fell to 80% ofbaseline. The anaesthetists were blinded to patientallocation. The time to peak pressor effect wasdetermined by blinded review of the arterial pressureprofiles at the completion of the study and analysed bythe Mann-Whitney U test. Repeated measures analysisof oscillometric SAP was performed using a generallinear model.

Results: Two subjects from group P were withdrawnbecause of Finapres failure and one subject from eachgroup did not need vasopressor. Peak pressor effect wasat a median of 27 (IQR 25-29) s after phenylephrineand 78 (IQR 49-92) s after ephedrine (P=0.006).Repeated measures analysis of three consecutiveoscillometric SAPs after injection of vasopressorshowed no significant difference between the groups(P=0.752).

Conclusion: We conclude that time to peak pressoreffect was significantly shorter with phenylephrine thanwith ephedrine.

Reference1. Ngan Kee WD, Lau TK, Khaw KS, Lee BB. Comparison of

metaraminol and ephedrine infusions for maintaining arterialpressure during spinal anesthesia for elective cesarean section.Anesthesiology, 2001; 95: 307-313.


O03 Intravenous vasopressors can affect rostralspread of spinal anaesthesia in pregnancy

DW Cooper, L Jeyaraj, R Hynd, R Thompson, T MeekD Ryall, MS KokriDepartment of Anaesthesia, James Cook UniversityHospital, Middlesbrough, UK

Introduction: We have previously observed anapparent association between rostral spread of spinalanaesthesia and choice of intravenous vasopressorgiven during caesarean section.1 This study tested thehypothesis that an intravenous infusion ofphenylephrine can reduce rostral spread of spinalanaesthesia in pregnancy, compared with ephedrine.

Method: Local hospital ethics committee approval wasgiven for this randomised double blind study comparingrostral spread of neural blockade when phenylephrine100 µg/mL (phenylephrine group, n = 30) or ephedrine3 mg/mL (ephedrine group, n = 30) was given byinfusion to maintain systolic arterial pressure duringspinal anaesthesia for elective caesarean section. TwomL of intrathecal plain levobupivacaine 0.5%combined with 0.4 mL of intrathecal fentanyl 50µg/mL, and 10 mL of epidural saline, was given in thesitting position. Block height was assessed by loss ofcold and light touch sensation to ethyl chloride spray 10and 20 min post spinal. Inadequate neural blockade wasdefined as an upper level of neural blockade to coldbelow T4, or to light touch below T6. The study wasdesigned to have an 80% chance of detecting a 24%difference in the incidence of cervical level neuralblockade to cold between the groups, at P = 0.05 (2-sided). The Mann-Whitney U test was used to comparedata. P <0.05 was considered significant.

Results: The groups were similar for patientcharacteristics and obstetric data. Mean systolic arterialpressure was similar in the two groups throughout thestudy. At 20 min, the median upper dermatome blockedto cold was T3 (IQR T2-T4) for the phenylephrinegroup, compared with T1 (T1-T2) for the ephedrinegroup (P = 0.001). The median upper dermatomeblocked to light touch was T5 (T4-T8) for thephenylephrine group, compared with T3 (T2-T6) for theephedrine group (P = 0.009). There was no differencein the incidence of cervical level block between the twogroups at 20 min, but the incidence of inadequate blockwas 43% in the phenylephrine group, compared with17% in the ephedrine group (P=0.025).

Conclusions: Intravenous phenylephrine can decreaserostral spread of spinal anaesthesia in pregnancy,compared with intravenous ephedrine. If phenylephrineis given instead of ephedrine to maintain systolicarterial pressure during caesarean section, the dose ofspinal anaesthetic may need to be increased to ensurean adequate level of neural blockade.Reference1. Cooper DW, Mowbray P. Can choice of vasopressor therapy

affect rostral spread of spinal anaesthetic? Anesthesiology 2003;98: 1524.

O04 Development of a new experimental model tostudy nociceptive pathways in the fetus

S Bresson, V Houfflin Debarge, S Jaillard, S Dalmas,P Deruelle, AS Ducloy , F Puech, L StormeDepartments of Obstetrics, Thoracic surgery, Pediatricsurgery, Anesthesiology and Neonatology, Hôpital J. deFlandre, CHRU, Lille, France.

Background: Many fetal diagnostic or therapeuticprocedures are performed without fetal anesthesia oranalgesia. The assessment of whether or when the fetusis likely to feel pain is presently based on an evaluationof anatomical evidence and on indirect neuroendocrineresponses to potential painful procedures.1,2 There is nodirect way to evaluate fetal pain. Previous clinicalstudies in adult humans have shown that thenociceptive flexion (RIII) reflex can be used as anobjective index.3 The aim of this study was to developan experimental model to investigate fetal nociceptivepathways.

Methods: The study was conducted on eight pregnantewes. Under sterile conditions, a fetal hind limb wasdelivered through a uterine incision. A pair ofelectrodes was placed near the sural nerve to performelectrical stimulation. Another pair of electrodes wasplaced in the ipsilateral flexor muscle to recordelectromyographic (EMG) responses. Catheters wereinserted in the femoral artery. The uteroplacentalcirculation was kept intact and the fetus replaced intothe uterus. The electrodes and catheters wereexteriorized through a subcutaneous tunnel to anexternal flank pouch. Measurements were performedbetween 128 and 138 days of gestation (term = 145days) with and without sufentanil infusion after aminimum recovery time of 5 days post surgery.

Results: An EMG response could be recorded 140 msafter the onset of electrical stimulation above athreshold intensity. The reflex magnitude increasedwith stimulus intensity (recruitment curve). Sufentanilinfusion decreased the reflex response. Fetalbradycardia was noted 10 s after the stimulation andwas not observed after sufentanil infusion. Plasmacatecholamine concentrations were not altered by thestimulation.

Conclusion: Our study shows that a nociceptive flexion(RIII) reflex can be recorded in the fetus. We suggestthat the RIII reflex can be used as a new tool to studythe ontogenesis of the nociceptive pathways and theeffects of analgesic drugs during fetal life.References1. Fisk NM, Gitau R, Teixeira JM, Giannakoulopoulos X,

Cameron AD, Glover VA. Effect of direct fetal opioid analgesiaon fetal hormonal and hemodynamic response to intrauterineneedling. Anesthesiology 2001; 95: 828-835.

2. Giannakoulopoulos X, Teixeira J, Fisk N, Glover V. Humanfetal and maternal noradrenaline responses to invasiveprocedures. Pediatr Res 1999; 45: 494-499.

3. Willer JC. Comparative study of perceived pain and nociceptiveflexion reflex in man. Pain 1977; 3: 69-80.


O05 Nociceptive stimuli alter the perinatalpulmonary circulation

A Delelis2, V Houfflin-Debarge2, B Larrue3, S Jaillard3,N Rouaix-Emery4, L Storme2, S Dalmas1, AS Ducloy 1

1Department of Anesthesiology, 2Department ofPerinatology, 3Department of Cardiothoracic Surgery,4Biochemistry Department, CHRU de Lille, France.

Aim of the study: The fetus is able to exhibit a stressresponse (increase in cortisol and catecholamines,tachycardia etc.) to painful events as early as 18 weeksof gestation. Stress hormones have been shown tomodulate pulmonary vascular tone and reactivity. Atbirth, an increase in stress hormones plays a significantrole in adaptation to postnatal life. We thereforepostulated that pain may alter the pulmonary circulationin the perinatal period. The hemodynamic response tointradermal injection of formalin, which is used inexperimental studies as a nociceptive stimulus,1 wasevaluated in chronically-prepared, late-gestation fetallambs.

Method: Eight ovine fetuses were operated on between128 and 130 days’ gestation (term: 147 days). Catheterswere placed in the ascending aorta, superior vena cava,main pulmonary artery and left atrium. An ultrasonicflow transducer was placed around the left pulmonaryartery. Three other subcutaneous catheters were placedin the lambs’ limb. Protocols started 5 days post-surgery. Hemodynamic responses to intradermal (i.d.)formalin (1%, 1 mL) (PROT 1), to i.d. formalin afterfetal analgesia by sufentanil infusion (loading dose 6µg, then 6 µg/h) (PROT 2), and to sufentanil infusionalone (PROT 3) were recorded. Blood concentrations ofcortisol and catecholamines were also measured. Theprotocols were approved by the “Comite d’Ethique dela Fondation de France”.

Results: PROT 1: 25 min after i.d. formalin, pulmonaryvascular resistances (PVR) increased by 35% (from0.7±0.04 to 1±0.04 mmHg·ml-1min-1; P<0.001) for onehour. Cortisol increased by 50% (P<0.05). PROT 2:during sufentanil infusion, PVR and cortisol did notchange significantly after i.d. formalin. PROT 3: PVRdid not change during sufentanil infusion.Catecholamine levels did not change during any of theprotocols.

Conclusions: Our results indicate that nociceptivestimuli may increase the pulmonary vascular tone. Thisresponse is not mediated by an increase in circulatingcatecholamine levels. Analgesia prevents this effect.We speculate that this pulmonary vascular response tonociceptive stimulation may explain some hypoxemicevents observed in neonates during painful intensivecare procedures.Reference1. Tjolsen A, Berge OG, Hunskaar S, Rosland JH, Hole K. The

formalin test: an evaluation of the method. Pain 1992; 51: 5-17.

O06 Provision of epidural analgesia in labour bynon-physicians: a pilot study

T McCarrick, J Curran, D Bogod, L Harrington,C McCormick, P Shuttleworth*Nottingham City Hospital, Nottingham and *DOHModernisation Agency, UK

Introduction: Concerned by the negative impact ofservice commitment to obstetric anaesthesia upontraining opportunities for trainee anaesthetists, two ofthe authors (JC, DB) determined to explore thefeasibility of training non-physician hospitalpractitioners as obstetric epidural assistants. Theobjective was to find out whether an appropriatelytrained practitioner could develop the competenciesneeded to provide routine epidural analgesia in labourwithout detriment to the safety or quality of the service.

Method: A detailed list of competencies was preparedby a multidisciplinary working party, relating toknowledge, attitude and skills. These were used to drawup a training programme, job description and personspecification. Local and national consultation tookplace with interested bodies, including the RoyalColleges of Anaesthetists and Midwives. Approval wasobtained from the Trust’s Clinical Risk ManagementCommittee. Leaflets were distributed to all antenatalpatients, and these were reinforced by further writtenand verbal information at the time of labour. Afterinternal advertisement and interview, two candidates, anurse and an operating department practitioner, wereappointed to be trained sequentially. Assistants attendedi.v. cannulation and Advanced Life Support courses,before spending approximately one month workingwith anaesthetists in main theatre practisingcannulation, airway management and airway skillsincluding tracheal intubation. They then moved tolabour ward, where all further training was carried outunder direct supervision by consultant anaesthetists.Epidural techniques were typically learned usingpatients undergoing elective caesarean section undercombined spinal-epidural anaesthesia, beforeprogressing to women in labour. Structured assessmentof progress was supplemented by external evaluation bya senior obstetric anaesthetist. Midwifery opinion wassought and potential anaesthetic time-saving evaluated.

Results: The first assistant (TM) has completed thecourse and will present her data. Briefly, 55 epiduralprocedures were completed satisfactorily. The tableshows details of epidural insertion in labouring women.Total 41Successful placement of catheter 38 (93%)Abandoned and handed to supervisor 3 (7%)Success at first space attempted 28 (68%)Success at second space attempted 10 (25%)Inadvertent dural punctures 0Conclusion: Provision of routine epidural analgesia inlabour can apparently be successfully delegated to anappropriately-trained non-physician practitioner.Training requires a tactful multidisciplinary approachdriven by enthusiastic senior support and sponsorship.


O07 Errors and omissions in anaesthesia: a pilotstudy using a pilot’s checklist

E Hart,* H Owen, A May*Flinders Clinical Skills and Simulation Unit, FlindersUniversity, Bedford Park, SA 5042, Australia, and*Department of Anaesthesia, Leicester Royal Infirmary,Leicester, LE2 7LX, UK.

Introduction: Airway problems during generalanaesthesia have been a major cause of maternalmortality. Now, so few general anaesthetics areadministered for caesarean section there are concernsthat anaesthetists will become deskilled and exposepatients to increased risk.1 Checklists are routinely usedin aviation to prevent accidents that could be caused bymemory lapse and they may also help anaesthetistswhen faced with an unusual event. We investigated theuse of an electronic checklist system developed for useby aircraft personnel (EC-TS electronic checklist,Aironautical Electronics Corporation Pty. Ltd) inpreparations for an emergency caesarean section undergeneral anaesthesia.

Method: Using a modification of the Delphi method,2 alist of items to be checked when preparing to administergeneral anaesthesia for a caesarean section was created.It was divided into equipment, drugs, monitoring andpatient checks. This was loaded onto the electronicchecklist system that was programmed to give verbalprompts and a written display.3 Its use was thenevaluated by 20 experienced anaesthetists using a high-fidelity anaesthesia simulator (Laerdal SimMan®) in arealistic operating theatre setting. They first made theirusual checks before administering a general anaestheticfor a caesarean section, and then repeated the scenariousing the checklist.

Results: Participants omitted to check a median of 13(range: 7-23) out of 40 items. Common omissionsincluded not checking that the difficult intubationtrolley was available and not optimising the patient’shead position.• 95% of participants felt that the checklist was useful• 80% would like to use it for practising simulated

scenarios• 40% would also use it in a clinical situation• 60% preferred a written and 40% the verbal checklist.

Conclusion: Important checks may be forgotten whenpreparing to give a general anaesthetic for caesareansection, and the use of a checklist may improve patientsafety. Many anaesthetists would like to practise usingchecklists and there may be a place for them inanaesthesia training.

References1. Johnson RV, Lyons GR, Wilson RC, Robinson APC. Training in

obstetric general anaesthesia: a vanishing art? Anaesthesia 2000;55: 179-183.

2. Bowles N. The Delphi Technique. Nurs Stand 1999; 13: 32-36.3. Checklist manual. Aironautical Electronics Corporation Pty Ltd

2002.

O08 Intravenous versus oral iron therapy forpostpartum anaemia

N. Bhandal, R. RussellNuffield Department of Anaesthesia, John RadcliffeHospital, Oxford, UK

Introduction: Postpartum anaemia occurs in up to 30%of women (Hb <10g/dL), in severe cases producingdebilitating symptoms.1 Most women either receive oralferrous sulphate or are offered a blood transfusion.However the transfusion trigger is clinician-dependentand varies widely. There is increasing concern aboutthe national shortage of blood products in the U.K.Intravenous ferrous dextran has been used to treatanaemia but is unpopular due to the risk of anaphylaxis.Ferrous sucrose is now available and is licensed for thetreatment of postpartum anaemia. We conducted aprospective randomised study investigating the efficacyof intravenous ferrous sucrose in comparison with oralferrous sulphate.

Methods: After ethical approval and written informedconsent, 44 women with Hb <9g/dL 24-48 h postpartum were randomised to receive oral ferroussulphate 200 mg b.d. for 6 weeks (Group O) orintravenous ferrous sucrose 200 mg two doses given onpost-partum days 2 & 4 (Group I). Haematologicalindices were measured before therapy (Day 0) and 5, 14and 40 days after the start of treatment. Statisticalanalyses included Students t-test, χ2and ANOVA.

Results: The groups did not differ at baseline incharacteristics or laboratory data. Mean values weresignificantly different for Hb and ferritin levels betweengroups at day 5 and 14 (P <0.01). At day 40 there wasno statistically significant difference between thegroups for Hb, but ferritin levels were significantlyhigher in group I (P <0.05) (table).

Group O Group IHb (g/dL) Day 1 7.5 (0.8) 7.3 (0.9)

Day 5 7.9 (0.6) 9.9 (0.7)*Day 14 9.0 (0.4) 11.1 (0.6)*Day 40 11.2 (1.2) 11.5(1.3)

Ferritin (µg/L) Day 1 11.0 (4) 13.0 (3)Day 5 12.0 (2) 48.0 (6)*Day 14 16.0 (4) 37.9 (5)*Day 40 15.0 (3) 42.2(7) **

Data are mean (SD) *P <0.01 **P <0.05

Conclusion: Although both regimens were effective inthe treatment of post-partum anaemia at day 40, theincreases in Hb and ferritin were statistically significantin group I within 5 days. Intravenous ferrous sucroseappears to provide a faster, alternative option in thetreatment of post-partum anaemia.

Reference1. Morrison JC, Morrison FG. Rational use of blood products in

obstetrics and gynecology. J Matern Fetal Invest 1994; 4: 147-153.


O09 Deprivation category and anaestheticintervention in the obstetric population

KN Litchfield, MG Booth*, SJ Young

Department of Anaesthesia, Princess Royal MaternityHospital, and *Glasgow Royal Infirmary, Glasgow, UK

Introduction: Lower socio-economic status has beenlinked to poor health, teenage pregnancy, low birthweight, pre-term delivery and poorer maternal andneonatal outcome.1,2 With these facts in mind, wepostulated that lower socio-economic groups would usemore anaesthetic services during labour and at the timeof delivery.

Method: We undertook a retrospective review oflabour ward admission and delivery data at a largetertiary referral maternity hospital from January toSeptember 2003. Anaesthetic intervention was definedas spinal, epidural or CSE insertions, or generalanaesthesia. Socio-economic status was measured usingthe deprivation category score ‘DEPCAT.’3 This is asystem that assigns an individual to one of seven (1=affluent, 7=most deprived) socio-economic groups,using their postcode sector. Statistical analysis includedStudents t-test for parametric data and Spearman’scorrelation (rho) co-efficient for non-parametric data.

Results: 1050 patients were identified. Fifty-two wereexcluded for incomplete data. The remaining 998patients were distributed as follows: DEPCAT 1=29,2=64, 3=95, 4=161, 5=93, 6=197, 7=359. DEPCATscores did not correlate with age, parity, gestation orbirth weight. There was a strong negative correlationbetween elective caesarean section rate (rho=-0.82,r²=0.68, P=0.023) and DEPCAT and reciprocally apositive correlation between SVD rate (rho= 0.96,r²=0.94, P=0.01) and DEPCAT. A lower anaestheticintervention rate was strongly correlated with anincreasing DEPCAT (rho=-0.829, r²=0.7, P=0.018),although when re-analysed with the exclusion ofanaesthesia for elective caesarean section, thecorrelation was no longer significant (rho=-0.571,r²=0.19, P=0.18).

Conclusion: Unexpectedly parturients in this study hada reducing anaesthetic intervention rate with increasingsocio-economic deprivation. This effect is explained bythe higher elective caesarean section rate in the moreaffluent groups. Further work is required to investigatewhy elective caesarean sections are conducted morefrequently in these higher socio-economic groups.

References1. Fraser AM, Brochert JE, Ward RH. Association of young

maternal age with adverse reproductive outcomes. N Eng J Med1995; 332: 1113-1117.

2. Gudmundsson S, Bjorgvinsdottir L, Molin J. Socioeconomicstatus and perinatal outcome according to residence area in thecity of Malmo. Acta Obstet Gynecol Scand 1997; 76: 318-323.

3. Carstairs V, Morris R. Deprivation and health in Scotland.Health Bulletin 1990; 48: 162-174.

O10 Suprasternal Doppler estimation of cardiacoutput following intravenous fluid preloadingfor caesarean section under spinal anaesthesia

T Selvan, R Fernando, J Bray, M Sodhi, M ColumbAnaesthesia Department, Royal Free Hospital, London,UK

Introduction: Hypotension may occur in up to 83%1 ofwomen during spinal anaesthesia for caesarean section,despite different fluid preloading regimens. We usedsuprasternal measurements of various linear andvolumetric Doppler indices, including maternal cardiacoutput (CO) and corrected flow time (FTc, a measure ofintravascular volume) following three preloadregimens, before and after spinal anaesthesia.

Method: After ethics approval, 60 healthy term womenawaiting elective caesarean section under spinalanaesthesia were recruited for this randomised doubleblind study. Baseline HR, BP, CO and FTc wererecorded in the left lateral tilt position before, and every5 min for 30 min after fluid preload, with one of threeregimens given over 15 min: Hartmann’s solution 1.5 L(CSL), 6% w/v Hydroxyethyl Starch 500 mL (HES 0.5)or 1 L (HES 1.0). After 30 min, spinal anaesthesia wasinduced with hyperbaric bupivacaine 12.5 mg andfentanyl 15 µg. Recordings continued every 5 min untilsurgery started. Hypotension (20% reduction in systolicBP treated with 6-mg ephedrine boluses), ephedrine useand umbilical cord blood gases were also recorded.Statistical analyses included RAMANOVA, ANCOVAand Tukey-Kramer tests (P <0.05).

Results: Patient data, HR, BP and cord gases weresimilar in groups. Although CO and FTc increased afterpreload in all groups (P <0.005), this was onlymaintained following spinal anaesthesia with HES 1.0(P <0.005). The differences in hypotension (%: 70 v 35v 65; P=0.069) and ephedrine use (mg: 10.4 v 5.7 v 9.7;P=0.26) between CSL, HES 0.5 and 1.0 groupsrespectively were not statistically significant.

Group Parameter Baseline Post preload Post spinalCO (L/min) 4.3 (0.66) 5.5 (0.94)∗ 4.8 (0.71)CSL

(n=20) FTc (ms) 340.3(29.34)

383.6∗

(28.11)349.0(27.71)

CO (L/min) 4.9 (0.79) 6.2 (1.16) ∗∇ 5.5(1.10)∗♦∇HES 0.5(n=20) FTc (ms) 346.3

(39.43)403.3∗∇

(42.71)364.9(42.8)

CO (L/min) 4.9 (0.62) 6.5 (1.31)∗∇ 6.1(1.41)∗∇HES 1.0(n=20) FTc (ms) 348.3

(30.16)409.5∗∇

(27.49)383.4∗∇

(31.47)Data are mean (SD) for all recorded measures; P <0.05 compared tobaseline*, post preload♦ or CSL∇

Conclusion: Despite CO and FTc increases followingfluid preload, particularly with HES 1.0, hypotensionstill occurred. This could be due to the inability of thesepreload regimens to compensate for reductions insystemic vascular resistance after spinal anaesthesia.

Reference1. Rout C, Rocke D. Prevention of hypotension following spinal

anesthesia for cesarean section. Int Anesthesiol Clin 1994; 32:117-135.


O11 Minimum effective dose of intrathecallevobupivacaine and ropivacaine forcaesarean section

R Parpaglioni, MG Frigo, A Lemma, M Sebastiani,G Barbati,* D CellenoDepartment of Anaesthesiology and Intensive Care,*AfaR – Centre of Medical Statistics & IT,Fatebenefratelli Hospital, Rome, Italy.

Introduction: In order to reduce the intrathecal dose oflocal anaesthetic we tried to extent the sequentialallocation method to women undergoing electivecaesarean section. The aim of the study was todetermine the median effective dose (ED50) of spinallevobupivacaine and ropivacaine for caesarean sectionand define this as the minimum effective dose (MED).

Methods: Sixty women, scheduled for electivecaesarean delivery, were allocated to receive CSE in theright lateral position, using the needle-through-needletechnique. After spinal injection, an epidural catheterwas located and the patient was turned immediatelysupine with left lateral tilt. Subjects were randomlydivided in two groups and received 3 mL of the studysolution intrathecally. In accord with preliminarystudies, the initial dose was 15 mg of levobupivacaineor 17 mg of ropivacaine. Subsequent doses weredetermined by the response of the previous patient inthe same group using up-down sequential allocation.1

Surgery was allowed to proceed if the upper dermatomelevel of loss of discrimination to pinprick was at leastT5. Anaesthetic efficacy was assessed using 100-mmvisual analogue pain score (VAPS) with ≤30 mm atskin incision, birth, peritoneal closure defined aseffective.2 Effective or ineffective responses determinedrespectively a 0.3 mg decrease or increase of the samedrug for the next patient.

Results: The MED50 of levobupivacaine for caesareansection was 10.95 mg (95% CI ± 0.33) and the MED50of ropivacaine 15.56 mg (95% CI ± 0.38), using theformula of Dixon and Massey.

Conclusion: The MED of spinal levobupivacaine andropivacaine for caesarean section suggest that thepotency ratio spinal levobupivacaine/ropivacaine is1.42. Further studies are in progress to establish theMED of other spinal local anaesthetics.

References1. Columb MO, Lyons G. Determination of minimum analgesic

concentration of epidural bupivacaine and lidocaine in labor.Anesth Analg 1995; 81: 833-837.

2. Gautier P, De Kock M, Huberty L. Comparison of the effects ofintrathecal ropivacaine, levobupivacaine, and bupivacaine forcaesarean section. Br J Anaesth 2003; 91: 684-689.

O12 Sevoflurane vs Entonox during labourcontractions

S Yeo, M Good, C Brennan, SM Yentis, A HoldcroftChelsea & Westminster Hospital, London, UK

Introduction: Entonox® (50% N2O/50% O2) is widelyused for pain relief during labour in the UK.Sevoflurane is reported to possess analgesic propertiesduring labour1 and our pilot study suggested theoptimum inspired concentration to be 0.8%.2 Wecompared these two inhalational agents during labourcontractions.

Methods: Following local research ethics committeeapproval, 33 parturients were recruited and randomisedin labour into two open-labelled, cross-over sequences:Entonox-sevoflurane-Entonox or sevoflurane-Entonox-sevoflurane. Each agent was given over 10contractions2 and 100-mm visual analogue scores forpain relief, pain intensity and sedation completedfollowing each contraction. Maternal pulse, BP andSpO2 and fetal CTG and Apgar scores were recorded.Women’s preferences were recorded at the end of thestudy. The data were summarised as median scores.Any possible effect of increasing labour pain wasexamined by comparing scores for each period withineach group; then t-tests were used to compare scoresbetween the groups.

Results: Thirty-one parturients took part. Twowithdrew due to the unpleasant odour of sevofluraneand six were withdrawn when they requested epiduralanalgesia. Pain relief and sedation scores forsevoflurane were higher for than for Entonox (table)but pain intensity scores were similar. Time had noeffect on pain relief or intensity scores. Twenty-ninemothers preferred sevoflurane to Entonox and found itssedative effects helpful. No adverse effects wereobserved and all the parturients remained responsivethroughout.

Median IQR RangePain relief score (mm)

sevoflurane 67 54.5-74 32.5-100Entonox 51 40-69.5 13-100

Sedation score (mm)sevoflurane 70 38.5-78.5 0-95.5Entonox 42.5 21.5-52 0-92

Conclusion: The use of sevoflurane resulted insignificantly higher pain relief scores than Entonox, butat the expense of more sedation. Although painintensity scores were similar with the two agents, 94%of mothers preferred sevoflurane. Finally, our resultsconfirm that pain relief during labour is more complexthan simply the absence of pain sensation.Acknowledgement: We thank L. Wickham for helping withrecruitment. S. Yeo was supported by an OAA Research Fellowship.References1. Toscano A, Pancaro C, Giovannoni S. Sevoflurane analgesia in

obstetrics: a pilot study. International Journal of ObstetricAnesthesia 2003; 12: 79-82.

2. Yeo S, Yentis SM, Brennan C, Holdcroft A, Stewart A.Sevoflurane as an inhalational analgesic in labour; a pilot study.International Journal of Obstetric Anesthesia 2003; 12: 198.


O13 Nalmefene for opioid-induced pruritus inlabor

C Grubb, P Balestrieri, S Prakalapakorn, H McAnallyDepartment of Anesthesiology, University of VirginiaHealth System, Charlottesville, Virginia, USA

Introduction: Pruritus occurs in up to 85% of laborpatients who receive neuraxial opioids.1 Naloxone, anopioid antagonist, is effective in treating side effects ofneuraxial opioids, but is very short acting and usuallyrequires a continuous intravenous infusion.2 Nalmefene,on the other hand, is another pure opioid antagonist, buthas a longer duration of action (12-15 h). To ourknowledge, no one has evaluated the use of nalmefeneduring labor. We are reporting an open-label pilot studyof nalmefene for opioid-induced pruritus in labor.

Methods: After approval of our human investigationcommittee, 20 labor epidural patients complaining ofpruritus were prospectively enrolled and givennalmefene 100 µg as an i.v. bolus in an open-labelmanner. A second bolus was offered after 30 min ifpruritus persisted. Pre- and post-nalmefene pruritus wasassessed using a treatment-based score: none, mild(pruritus without request for intervention), moderate(intervention requested) or severe (unbearable pruritus).Pain was assessed using a 10-cm visual analog scale(VAS) before and 30 min after intervention.

Results: Rate of overall improvement to mild or nopruritus was 80%. Complete resolution of pruritusoccurred in 65% of patients within 30 min of nalmefeneadministration. Non-responders (20%) were given asecond dose of nalmefene 100 µg i.v. for severepruritus, but showed no subsequent improvement. Aftertreatment failure with nalmefene, half the non-responders received naloxone infusions, completelyaborting pruritus in each. Before and after nalmefene,all patients reported adequate labor analgesia (VAS<4/10); and no analgesia regimen changes wererequired after nalmefene. None of the respondersrequired additional pruritus treatment before delivery,and no side effects or adverse events occurred afternalmefene administration.

Discussion: Our results suggest that nalmefene is a safeand effective alternative to naloxone for opioid-inducedpruritus during labor. Though nalmefene did not appearto antagonize analgesia in our small cohort, the studywas not powered to detect small differences inanalgesia. Regardless, nalmefene is easier to dose andadminister than naloxone. Consequently, randomized,placebo-controlled trials are needed to further evaluatethis drug during labor for opioid-related side effects.

References1. Baraka A, Noueihid R, Hajj R.Intrathecal injection of morphine

for obstetric analgesia. Anesthesiology. 1981; 54: 136-140.2. Kjellberg F, Tramer MR. Pharmacological control of opioid-

induced pruritus: a quantitative systematic review ofrandomised trials. Eur J Anaesthesiol. 2001; 18: 346-357.

O14 Comparison of measured and estimatedangles of operating table tilt among varyinggrades of anaesthetists

A Swami, P Sharpe, TM BourneDepartment of Anaesthesia, Leicester Royal Infirmary,Leicester, U.K.

Introduction: We wanted to establish whether thegrade of anaesthetist influenced the ability to estimatethe tilt of an operating table to 15°. In pregnancy,aortocaval compression is exacerbated by lying supineand has an adverse effect on the mother and fetus,1

which may be reduced by lateral tilt. The commonrecommendation of 15° lateral tilt was described byCrawford and colleagues in 19722 and showedsignificant improvement in fetal well-being. Morganand colleagues3 found that estimating angles by eyewas grossly inaccurate. Jones et al.4 stated that usuallythe measured angle was lower than the estimated angleand they were unsure about its clinical significance.

Method: We assessed four groups of 10 anaesthetists.Group A were obstetric consultants, group B non-obstetric consultants, group C junior SpRs with threemonths’ training in obstetrics and group D noviceSHOs with no experience in obstetric anaesthesia. Thesame non-pregnant volunteer was lying on the table forevery assessment. Everybody was asked to tilt the table15° to the left. The table used was manually controlledand at the other end of the table, which could not beseen by the anaesthetist tilting the table, the angle wasmeasured with a protractor and a hanging weight.

Results: Out of 40 anaesthetists, nobody correctlyestimated 15° left lateral tilt. The measured angle of tiltwas always smaller than 15°. There was a statisticallysignificant (P = 0.047) difference between the SHO andobstetric consultant groups. Other groups did not showa statistically significant difference. The range of tiltvaried between 5° and 14°.

Conclusion:1. Nobody estimated 15° correctly, therefore operating

tables should have a simple device to show the angleof tilt.

2. The experience of the obstetric anaesthetists (groupsA, B & C) made no difference to their ability toestimate 15° left lateral tilt.

References1. Lees MM, Scott DB, Kerr MG, Taylor SH. The circulatory effects

of recumbent postural change in late pregnancy. Clin Sci 1967; 32:453-465.

2. Crawford JS, Burtan M, Davies P. Time and lateral tilt atcaesarean section. Br J Anaesth 1972; 44: 477-484.

3. Morgan DJ, Whitewam JG, Spencer JAD. Aortic compression bythe uterus; identification with Finapres digital arterial pressureinstrument. Br J Obstet Gynaecol 1990; 97: 700-705.

4. Jones SJ, Kinsella SM, Donald FA. Comparison of measured andestimated angles of table tilt at caesarean section. Br J Anaesth2003; 90: 86-87.


O15 Use of Semmes-Weinstein monofilaments fortesting spinal anaesthetic block level forcaesarean section

GA Vickers,a G Yuill, R Clark, T Ramsayb

Departments of Anaesthesia, Manchester RoyalInfirmary, bStepping Hill Hospital, Stockport, andaRoyal Oldham Hospital, UK

Introduction: When testing the height of spinalanaesthesia for caesarean section, cold is thecommonest testing stimulus although there is evidencethat light touch is the most reliable.1 Cotton wool, fluiddrops and fingers are inconsistent. Semmes-Weinsteinmonofilaments are nylon fibres of uniform calibre andlength on a handle. They bend when a given force isapplied, giving a reproducible stimulus. They are usedclinically in peripheral neuropathy screening and arecheap, easy and acceptable. The aim of this study wasto compare monofilaments with the commonly usedmethods of ethyl chloride, pinprick and cotton wool.

Method: 54 patients due to undergo elective caesareansection under spinal anaesthesia were recruited. Spinalblock was performed using hyperbaric bupivacaine andtested with ethyl chloride. Two further anaesthetistsused additional tests to measure the height of the block,one with a 10-g monofilament, the other with pinprick,cotton wool or ethyl chloride, determined randomly.The order of these additional tests was also randomised.Levels of block and sensation of pain intra-operativelywere recorded blind.

Results: 44 patients’ results were analysed. The other10 had intrathecal opioid. Compared to themonofilament, the median difference in block heightmeasured by ethyl chloride was 1.5 dermatomes, ethylchloride being higher (Wilcoxon signed ranks test, 95%CI 1–2). Cotton wool was 1 level lower (NS), and pin-prick was 0 dermatomes removed (NS). Ethyl chlorideas the first test against ethyl chloride as a subsequenttest showed no median difference. Correlation withmonofilament was good for cotton wool (Kendal tau b0.86, 95% CI 0.66-1), fairly good with ethyl chloride(0.56, 0.41-0.7), and possibly good with pinprick (0.62,0.29-0.95). Weighted kappa coefficients suggest highagreement of monofilament block level (0.88) to cottonwool, moderate for pin (0.51) and fair for ethyl chloride(0.35). Six patients complained of pain. All were testedwith the monofilament (block level T6–T10) and ethylchloride (T4–T7). Four were tested with pinprick (T5–T6) and one was tested with cotton wool (T8). Receiveroperator characteristic curves seem more favourable formonofilament than for pin or wool.

Conclusion: In using monofilaments to assess spinalblock there was good correlation with the other testingmethods, most strongly cotton wool. Monofilamentsmay be a more specific predictor of “no pain” thaneither ethyl chloride or pinprick.Reference1. Russell IF. Assessing the block for caesarean section.

International Journal of Obstetric Anesthesia 2001; 10: 83-85.

O16 How long should you have to wait? An auditof transfers from a low risk to a high riskhospital birth centre

N Bolad, D Hart*, J Wolfe-Barry, G O’SullivanDepartment of Anaesthesia & *Department of Women’sHealth Services, St Thomas’ Hospital, London, UK

Introduction: One of the implications of the ChangingChildbirth Report1 has been an increase in the numberof Home-from-Home style low risk birth units in theUK.2 These units provide a more homely environmentbut with quick access to emergency interventions ifrequired. Women are also referred to the higher riskHospital Birth Centre for epidural analgesia whenunable to cope. This audit aims to identify theefficiency with which labouring women are referredfrom a low risk care setting to a higher risk birth centre,when medical intervention is required.

Methods: This prospective audit was conducted duringa three-month period from mid August to midNovember 2003. Data collected included patientdetails, reasons for and action after transfer, time takento transfer and time of medical review. Other measureswere maternal and neonatal outcome. Data wereanalysed using Microsoft Excel 2000. A χ2 test wasused to compare the two birth centres (Intercooled Stata8 statistical software).

Results: Five hundred and forty one women wereadmitted to the low risk Home-from-Home birth centreduring the audit period.

n or median (range)Transferred to hospital birth centre 210/541 (39%)Outcome forms completed 197/210 (94%)Reason epidural analgesia 48/197 (24%)

failure to progress 42/197 (21%)decision to transfer 25 min (0-970).Timingsdecision to review 85 min (2-1466)epidural request tocompletion

27 min (10-285)

Intervention was higher in the group transferred than inthose booked to the higher risk birth centre (29.4% v19.4%, χ2 10.34, P <0.001). This was independent ofthe need for epidural analgesia. The caesarean sectionrate for women admitted to the Home-from-Home was6.8% (37/541).

Conclusion: Although this audit may not be areflection of all maternity units that offer low risk/ highrisk birthing centres, it does however highlight thecomplexities of trying to provide such a service to thepublic. What physiological and psychological effectdoes a delay in transfer have on a labouring woman?

References1. Dept of Health. Changing Childbirth: Report of the Expert

Maternity group. London: HMSO, 1993.2. Kirkham M (Ed). Birth Centres: A Social Model for Maternity

Care. Oxford: Books For Midwives, 2003.


O17 Antenatal assessment of high risk pregnancy:A survey of UK practice

M Rai, S Lua, R Russell, M PopatNuffield Department of Anaesthetics, John RadcliffeHospital, Oxford, UK

Introduction: National guidelines have recommendedearly involvement of anaesthetists in high-riskpregnancy.1,2 Consequently obstetric anaesthetists areincreasingly involved in the management of high riskpregnancy although few hospitals have dedicatedclinics for antenatal assessment. This national surveyaimed to evaluate facilities available for antenatalanaesthetic assessment in UK obstetric units.

Method: With the OAA Seal of Approval postalquestionnaires were sent to lead anaesthetists in 256UK obstetric units. Information was requested on unitsize, consultant cover and facilities for antenatalassessment of high risk cases. Opinions were sought asto the need for such clinics in individual units.

Results: Replies were received from 196 units(response rate 77%). Only 59 units (30%) ran a highrisk antenatal assessment clinic. Of these, 7% were heldmore than once a week, 40% were weekly, 25%fortnightly, 29% monthly. Larger units were morelikely to have formal assessment clinics; 27% of clinicsrelied on written referrals, the remainder usingappointments after direct contact with the obstetricanaesthetists. In units without a formal clinic, informalreferral for anaesthetic consultation was mostcommonly used (70%) with written referral used in theremaining 30%. Screening questionnaires produced byobstetric anaesthetists were used in 7% of units withouta clinic. Of the 137 units without an antenatalassessment clinic, 53 (39%) stated that such a clinicwould be beneficial.

Discussion: A minority of UK units run a formalanaesthetic antenatal high-risk assessment clinic despiterecommendations for early anaesthetic involvement inhigh risk cases. Reasons for not instituting clinics werereported to be financial constraints, lack ofcommunication with obstetricians and midwives,inconvenience for pregnant women requiring extrahospital appointments and lack of demand especially insmaller units. Those units with a clinic were extremelypositive regarding their role in the management of high-risk pregnancy.

References1. Association of Anaesthetists of Great Britain & Ireland,

Obstetric Anaesthetists Association. Guidelines for ObstetricAnaesthesia Services, London 1998.

2. Why Mothers Die 1997-99. The Confidential Enquiries intoMaternal Deaths in the United Kingdom. London: RCOG Press2001.

O18 Epidural analgesia for parturients with type Ivon Willebrand disease

D Marrache, FJ Mercier, C Boyer-Neumann,*D Meyer,* D BenhamouDépartement d’Anesthésie-Réanimation, *Serviced’Hématologie, Hôpital Antoine Béclère, Clamart-France

Introduction: Epidural analgesia is usuallycontraindicated in von Willebrand disease (vWD),although in type I vWD, the increased synthesis of vonWillebrand factor (vWF) and F.VIII:C duringpregnancy can lead to a correction of biologicalabnormalities1 and may allow epidural analgesia to beperformed for delivery.2

Methods: The clinical files of pregnant patients withtype I vWD who delivered in our tertiary level perinatalunit were reviewed. The time profile of haemostasisabnormalities during pregnancy was recorded, as wellas technical feature and safety of epidural analgesiawhen performed.

Results: Sixteen pregnancies (13 patients) wereincluded. Mean levels of clotting factors (±SD) becamenormal in all cases at the end of pregnancy (table).

FVIII:C vWAg vWRCo

Before pregnancy 42% ± 12 46% ± 8 42% ± 10

End of pregnancy 142% ± 42 142% ± 61 142% ± 79

Nine epidurals (6 patients) were performed withoutcomplication. Three parturients did not receive epiduralanalgesia despite normal biological haemostasis,because the anaesthesiologist was reluctant to performit. Four other parturients had a closure time on PFA-100 (n=3) or a bleeding time (n=1) that remainedprolonged; epidural analgesia was not performed forthis reason.

Conclusion: vWF and F.VIII:C deficits returned tonormal values in all cases at the end of pregnancy inthis series of parturients with type I vWD. However,sophisticated platelet aggregation tests with PFA-100uncovered unexpected abnormalities whose origin andclinical significance remain undefined. Based on ourstudy and another small series,2 epidural analgesiaappears safe for delivery in type I vWD but aspecialised follow-up seems wise for these patientsduring pregnancy.

References1. Chediak JR, Alban GM, Maxey B. Von Willebrand’s disease

and pregnancy: Management during delivery and outcome ofoffspring. Am J Obstet Gynecol 1986; 155: 618-624.

2. Kadir RA, Lee CA, Sabin CA, Pollard D, Economides DL.Pregnancy in women with von Willebrand’s disease or factor XIdeficiency. Br J Obstet Gynaecol 1998; 105: 314-321.


O19 The EXIT procedure – two case reportsD Shetty, A Gunatilleke, A Relwani, J ClarkeDepartment of Anaesthesia, St George’s Hospital,Tooting, London, UK.

Introduction: We describe the anaestheticmanagement of two pregnancies where the fetuses werediagnosed antenatally as having large facial andcervical tumours that were obstructing the oropharynx.In both cases it was anticipated that there would bedifficulty in securing the baby’s airway at the time ofbirth that could lead to fetal hypoxia and possibleasphyxia. The ex-utero intrapartum therapy (EXIT)procedure is a recognised method of managing suchcases involving a modified caesarean section with thefirst stage being delivery of the fetal head. The fetus isanaesthetised and paralysed and fetal oxygenation ismaintained throughout by preserving the normal utero-placental circulation and preventing uterine contraction.Once the fetal airway is secure by either intubation ortracheostomy, the fetus is delivered in the normalmanner and a conventional caesarean sectioncompleted.

Case reports: General anaesthesia was employed inboth cases, and tocolysis achieved with high-doseinhalation anaesthesia in one and inhalation anaesthesiawith nitroglycerin intravenous infusion in the second. Inboth cases the fetal airway was secured by intubationwithin 20 minutes without any compromise to fetaloxygenation or heart rate. In both cases maternal bloodloss was greater than 2000 mL and once the umbilicalcord was clamped, tocolysis was reversed and oxytocinadministered. Both mothers had uneventful post-operative periods and were discharged home at thenormal time.

Discussion: The EXIT procedure has been successfullyused for congenital diaphragmatic hernia1 andcongenital airway obstruction.2 It requires amultidisciplinary approach involving obstetricanaesthetists, obstetricians, fetal medicine,neonatologists, paediatric anaesthetists and paediatricENT surgeons. The challenge for the obstetricanaesthetists is to maintain adequate maternal bloodpressure and oxygenation, utero-placental blood flow,thermoregulation for mother and fetus and completeuterine relaxation until the fetal airway is secured. Oncethe fetal airway is secured and the baby delivered, theaim is to achieve uterine contraction and replace anyblood loss.

References1. Sachiyo S, Tomoaki T, Yamanouchi T. Fetal stabilisation for

antenatally diagnosed diaphragmatic hernia. J Paediatr Surg 1999,34: 1652-1657.

2. Liechty KW, Crumblehome TM. Management of fetal airwayobstruction. Semin Perinatol 1999; 23: 496-506.

O20 Analgesia for labour in the region of Paris(Ile de France)

P Abecassis, FJ Mercier, D BenhamouHôpital Antoine Béclère, Clamart - France

Introduction: The French survey called “Three Daysin Anaesthesia” performed in 1996-97 showed that theepidural rate for labour pain relief is very high inFrance (>50%).1 Nevertheless, organisation andpractices have never been fully surveyed in France,unlike other in countries.2

Methods: A questionnaire including 26 questions wassent in 2003 to the lead anaesthetist of the 105 obstetricunits in the region of Paris (Ile de France) to examineorganisation and practices in relation to labouranalgesia. A national panel of experts in obstetricanaesthesia tested the questionnaire before it was sent.

Results: There were 96 answers (91%) coming fromuniversity teaching hospitals (19%), communityhospitals (30%) and private maternities (51%). Theannual number of deliveries ranged between 1500 and2000 in 17% of institutions and >2000 in 31%. Theepidural rate was >60% in 91% of institutions and nonehas an epidural rate <20%. Preloading >500mL wasregularly used in 76% of units. Ropivacaine was thelocal anaesthetic (LA) routinely used by 75% ofrespondents. Ropivacaine 0.2% and bupivacaine 0.25%were used by 55% of anaesthetists. Sufentanil wascombined with LA in every patient for 74% ofrespondents. Routine use of clonidine or adrenaline asan adjuvant was reported by 16% of anaesthetists.Spinal analgesia and walking epidurals were neverperformed in 41% and in 90% of institutions,respectively. A coagulation test was required either inthe last month or in the last 24 h of pregnancy by 79%and 21% of anaesthetists, respectively. PT-PTT andplatelets count were required in 90% and 97% of cases,respectively. Very similar results were noted for theanalgesic management of twin or breech deliveries.

Conclusions:The epidural rate in the region of Paris isvery high. A wide use of preloading is surprisinglynoted in this survey. The desire to avoid motorblockade is demonstrated by the large use ofropivacaine and by the widespread use of combinationwith a lipophilic opioid. Injection of clonidine and/oradrenaline containing solutions and walking epiduralsare marginal practices.

References1. Auroy Y, Laxenaire MC, Clergue F et al. Anesthésies en

obstétrique. Ann Fr Anesth Réanim 1998; 17: 1342-1346.2. Breen TR, McNeil T, Dierenfield L. Obstetric anesthesia practice

in Canada. Can J Anesth 2000; 47: 1230-1242.


O21 Asepsis for neuraxial analgesia in labour: asurvey in the region of Paris (Ile de France)

P Abecassis, FJ Mercier, D BenhamouHopital A Béclère, Clamart, France

Introduction: In 1998, French recommendationsconcerning hygiene in anaesthesia were published.1

However, because controversy exists in France as towhich aseptic precautions should be used whenperforming a neuraxial block for acute pain relief,2 thissurvey tested the hypothesis that wide variations inpractice continue to exist.

Methods: A questionnaire was sent in 2003 to the leadanaesthetist of the 105 obstetric units in the region ofParis (Ile de France) to examine practices in relation toasepsis when a neuraxial analgesia for labour isperformed. The questionnaire was tested by a nationalpanel of experts in obstetric anaesthesia before beingsent.

Results: There was 96 answers (91%). A protocoldescribing asepsis practices was available in 40% ofanaesthesia departments. Wearing a surgical face maskand a cap was routine for 61% and 54% of respondents,respectively. A long-sleeved sterile surgical gown wasused by 16% of respondents. One anaesthetist did notbelieve that sterile gloves were essential and two didnot use sterile surgical drapes. Alcoholic solution forskin disinfection of the patient’s back was used by 89%of respondents.

Conclusion: Except for the wide use of alcoholicantiseptic solutions (89 %), which is in accordance withcurrent data,3 this survey reveals poor compliance by alarge number of French anaesthetists even to the mostbasic features of antiseptic protection when placing aneuraxial block for labour analgesia. These results areseen although French recommendations have recentlybeen published.1 Although apparently surprising, theseresults are in the line with other surveys performed inFrance4 and elsewhere,5 showing several inadequateattitudes. These large variations in practice areprobably related to the absence of valid scientific datafrom randomised studies and to the rarity of infectiousevents in this context. More work is needed todisseminate sound and practical protocols.

References1. Auboyer C. Risque infectieux et anesthésie locorégionale. Ann Fr

Anesth Réanim 1998; 17: 1257-1260.2. Benhamou D, Mercier JF, Dounas M. Hospital policy for

prevention of infection after neuroaxial blocks in obstetrics.International Journal of Obstetric Anesthesia 2002; 11: 1-5.

3. Clevenot D, Robert S, Debaene B, Mimoz O. Analyse critique dela littérature sur l’utilisation comparée de deux antiseptiques lorsdu cathétérisme vasculaire ou rachidien. Ann Fr Anesth Reanim2003; 22: 787-797.

4. Sleth JC. Evaluation des mesures d’asepsie lors de la réalisationd’un cathétérisme épidural et perception de son risque infectieux.Résultats d’une enquête en Languedoc-Roussillon. Ann Fr AnesthRéanim 1998; 17: 408-414.

5. Sellors JE, Cyna AM, Simmons SW. Aseptic precautions forinserting an epidural catheter: a survey of obstetric anaesthetists.Anaesthesia 2002; 57: 593-596.

O22 Determining the density of levobupivacaineand ropivacaine at 37°

M Camorcia, G CapognaDepartment of Anaesthesia, Città di Roma Hospital,Rome, Italy

Introduction: The density of a spinal anaestheticsolution relative to human CSF is an importantdeterminant of extent of subarachnoid block.1 Theaddition of glucose to local anaesthetics is known toincrease their density.2 Our laboratory-based studyaimed to make accurate density measurements of thenewer local anaesthetics.

Method: For the purpose of the study we usedcommercially-available local anaesthetic solutions. Weadded to the local anaesthetic solutions differentsaline/glucose combinations to obtain a final glucoseconcentration of 8.4%. The densities of localanaesthetic solutions were measured at 37°C (±0.01°C)using a density meter technique (DR45 Combinedmeter, Metler Toledo Inc, OH, USA) with an accuracyof +/- 0.00001 g/mL. For each solution tested, a meanvalue was recorded from five density readings.

Results: Results are provided in the table. Specificgravities are expressed as mean (g/mL) ± standarddeviation.Table

Local anaesthetic Density

Levobupivacaine 0. 25% 1.0072 ± 0.00000Levobupivacaine 0. 5% 1.0071 ± 0.00001Levobupivacaine 0. 75% 1.0089 ± 0.00001Levobupivacaine 0.5% + glucose 1.0358 ± 0.00001Ropivacaine 0.1% 1.0065 ± 0.00000Ropivacaine 1% 1.0069 ± 0.00001Ropivacaine 0.5% 1.0048 ± 0.00000Ropivacaine 0.5% + glucose 1.0318 ± 0.00000Ropivacaine 0.75% + glucose 1.0315 ± 0.00001

Data are mean (± SD)

Conclusion: We determined values for the densityof levobupivacaine and ropivacaine with or withoutglucose.

References1. Horlocker TT, Wedel DJ. Density, specific gravity and baricity of

spinal anesthetic solution at body temperature. Anesth Analg 1993;76: 1015-1018

2. Nicol ME, Holdcroft A. Density of intrathecal agents. Br J Anaesth1992; 60: 60-63.


O23 Audiometric changes after post duralpuncture headache and epidural blood patch

E Powel, S Gowrie-Mohan, C Fortescue,R Rajamanicam*Department of Anaesthesia, Department of ENT*,Lister Hospital, Stevenage, UK

Introduction: Several recent reports have describedlow-frequency hearing loss after dural puncture. Asingle hearing test after the onset of post dural punctureheadache (PDPH) may be of limited value if the predural puncture hearing level is not known. The aim ofthis study is to investigate whether there is anyimprovement of low-frequency hearing loss associatedwith PDPH after epidural blood patch (EBP).

Method: Patients were identified as part of an ongoingprospective audit of PDPH and its associatedsymptoms. Following ethics committee approval, 28patients were recruited to take part in this study. Puretone audiometry was performed before and after EBP.Each patient’s subjective feeling of hearing loss and theimprovement after EBP were recorded. The paired t-testwas used for statistical analysis.

Results: Four patients were excluded because ofinspissated cerumen and history of deafness. Other 24patients in our sample (mean age 41.8 years) had PDPHfrom the following sources: 16 gauge needle (n=14), 20gauge (n=2), 22 gauge (n=2), 25 gauge (n=5),discectomy (n=1). Ten of the 24 patients had asubjective feeling of hearing loss (41.6%) before theblood patch was carried out and all 10 patients felt thattheir hearing loss improved afterwards. Hearing losswas reduced by EBP (table). The difference wassignificant (P <0.0001).

Table: Mean 250-1000 Hz hearing level (dB)(negative values indicate decreased hearing)

Mean SE Range

Before EBP -20.87 -1.46 -15 to -40

After EBP -8.91 -0.7 -5 to -15

Conclusion: From our series, there was a statisticallysignificant improvement in low-frequency hearing lossassociated with PDPH after EBP. A single hearing testafter the onset of PDPH may be of limited value if thepre dural puncture hearing level is not known.However, pure tone audiometry may be a useful aid inthe presence of atypical PDPH syndrome and persistentPDPH after EBP, but a larger study would be needed toascertain this.

Reference1. Fog J, Wang LP, Sundberg A, Mucchiano C. Hearing loss after

spinal anesthesia is related to needle size. Anesth Analg 1990;70: 517-522.

O24 A survey of the management of accidentaldural puncture and post dural punctureheadache in UK obstetric practice

R. Baraz, R.E.CollisDepartment of Anaesthetics, University Hospital ofWales, Cardiff, UK

Introduction: The management of an accidental duralpuncture and post dural puncture headache (PDPH) inobstetric practice continues to be of great interest. Thissurvey explores the current management of the aboveand compares the findings to a similar surveyconducted in 1993.1

Method: An Obstetric Anaesthetists’ Association(OAA) approved questionnaire was sent to leadobstetric anaesthetists in all 248 maternity units in theUK. The questionnaire asked about the management ofthe epidural catheter after accidental dural puncture andthe commonly used methods of prophylaxis andtreatment of post dural puncture headache.

Results: There was a return rate of 69% (171/248).Most units (85%) now have written guidelines for themanagement of accidental dural puncture compared to58% in 1993. The remaining 15% either do not haveguidelines or are in the process of writing them.Twenty-nine percent of units now routinely place theepidural catheter spinally, 40% re-site the catheter andthe remaining 31% allow either option by leaving it upto the operator. This is in contrast to the previoussurvey where 99% of catheters were re-sited. Only 18%of units now limit the second stage of labour and 11%avoid pushing and deliver by ventouse or forceps,whilst the majority (68%) allow labour to take placewithout any intervention. Previously 46% of unitsallowed labour to proceed without intervention.Following delivery, prophylactic measures to preventPDPH are as follow: 91% encourage fluid intake, 83%give regular pain killers, 18% routinely give acrystalloid bolus or infusion into the epidural space andonly 3% perform a prophylactic epidural blood patch(EBP) compared to 8.6% previously. Twenty-sevenpercent of units now treat PDPH with EBP as soon as itis diagnosed whilst the majority (73%) perform EBPonly after failure of conservative treatment.

Conclusion: Compared to the 1993 survey, morematernity units now have written guidelines. Thebiggest change in practice is the intentional placementof the epidural catheter into the spinal fluid to maintainlabour analgesia (up to 60% versus only 1% in 1993).Fewer units are in favour of prophylactic EBP anddoubts still exist in performing an EBP as the majorityof units still wait until conservative management fails.

Reference1. Sajjad T, Ryan TD. Current management of inadvertent dural taps

occurring during the siting of epidurals for pain relief in labour. Asurvey of maternity units in the United Kingdom. Anaesthesia1995; 50: 156-161.


O25 Is maternal preparation for emergencyobstetric anaesthesia adequate?

C Fortescue,* MYK Wee,* SM Yentis,† S Malhotra,†

A Holdcroft†

*St Mary’s Hospital, Poole & †Chelsea andWestminster Hospital, London, UK

Introduction: Emergency procedures are potentiallytraumatic events with long term sequelae.1 Womenprefer to feel in control and receive information beforeinterventions.2 In emergencies, lack of time can hindercommunication and little is known about thequantity/quality of anaesthetic information imparted.We sought to assess this based on previous audits ofnon-emergency obstetric interventions.

Method: A structured questionnaire was developedfrom surveys of elective procedures. After writteninformed consent, mothers who had had emergencyprocedures were questioned during routine follow-upand additional details noted from their records.

Results: To date, 58 women have participated. Mostunderwent category-2 (39; 67%) or category-1 (9; 15%)caesarean section; 5 (9%) had forceps delivery and 5(9%) had removal of retained placenta. Thirty-one(53%) already had an anaesthetic intervention (epiduralanalgesia). Two (3%) required HDU care before, and 5(9%) after, anaesthesia. Thirty women (52%) had priorinformation about emergency anaesthesia, 13 (22%)from antenatal classes/visits and 7 (12%) from theirown reading. The others had no prior knowledge untiltold, usually by the obstetrician, before the procedureitself. Information was verbal in 41 cases (71%),written in 5 (9%), and in 12 (20%) from combinedsources e.g. past experience or friends/family. Previousgeneral anaesthesia helped women understand theobstetric emergency in only 11/40 cases (28%) butprevious obstetric experience was considered useful by12/13 (92%). Women were ‘very satisfied’ (90%) or‘satisfied’ (10%) with the level of information providedalthough they did express some preferences (Table).Table 1: Preferences for anaesthetic information

How Who WhenVerbal 31Written 16Video 1Combined 10

Anaesthetist 24Midwife 22Obstetrician 3Combined 9

Antenatal 34Admission 7Before op 12Combination 5

Conclusion: Though half of the women knew relativelylittle about anaesthesia beforehand, reassuringly mostwere very satisfied with this level of information. Themost frightening events were regarding the efficacy ofregional anaesthesia and ideally more information couldbe provided to prepare women better for this.

References1. Ryding EL, Wijma K, Wijma B. Experiences of emergency

caesarean section: a phenomenological study of 53 women.Birth 1998; 25: 246-251.

2. Brown S, Lumley J. Satisfaction with care in labour and birth: asurvey of 790 Australian women. Birth 1994; 21: 4-13.

O26 Spinal levobupivacaine for cesarean sectioncauses less hypotension and motor block thanracemic bupivacaine

HC Coppejans, MP VercauterenUniversity Hospital Antwerp, Edegem, Belgium

Introduction: Several previous studies have suggestedthat ropivacaine but also levobupivacaine may causeless motor block and/or hypotension than racemicbupivacaine. The present study was intended to verifywhether this is the case with low dose spinal anesthesiapreceeded by prehydration and prophylactic ephedrine.

Methods: After Hospital Ethics Committee approvaland written informed consent 70 parturients scheduledfor elective cesarean section were randomized toreceive in a double-blind fashion either spinallevobupivacaine (L-group) or racemic bupivacaine (B-group) as part of a combined spinal-epidural technique.The intrathecal dose of local anesthetic was 6.6 mg towhich was added sufentanil 3.3 µg. Patients wereprehydrated with crystalloid 1000 mL and 6%pentastarch 500 mL and after spinal injection receivedephedrine 5 mg. Vital signs and highest sensory andmotor block were recorded every 2 min. Side-effectswere recorded throughout the study period. Neonataloutcomes were also recorded.

Results: Sixty-five patients remained in the study andfive were discarded due to protocol violation, theoccurrence of spontaneous contractions just beforetransfer to the operating theatre, or dural or bloody tap.The mean upper sensory level was T3 in both groups.Differences between the two groups are given in thetable.Group B LSensory level ≤T5 or ≥T1* 11 (34%) 3 (9%)Epidural supplementation

needed antepartum4 (12%) 1 (3%)

Ephedrine supplement needed* 16 (50%) 9 (27%)Nausea* 8 (24%) 16 (50%)Motor block Bromage 3** 19 (59%) 6 (18%)Mean ± SD lowest systolic

pressure (mmHg)*103±18 114±20

Difference between groups: *P <0.05, ** P<0.01There were no differences in neonatal outcome data.

Conclusions: Levobupivacaine results in a morereliable block while the lower intensity of motor blockmay be a more pleasant experience for the patient aswell. This may also accelerate discharge to the ward.The better hemodynamic profile of levobupivacainemay be evidenced by higher blood pressure values, lessnausea and fewer patients requiring additionalephedrine.


O27 The analgesic efficacy of regionallevobupivacaine compared to epiduralanalgesia after caesarean delivery

P Ranta, J Kukkonen, N Rawal,* P Ohtonen,T Raudaskoski,+ T Ala-KokkoDepartment of Anaesthesia and + Gynaecology andObstetrics, University Hospital Oulu, Finland and*Department of Anaesthesia, University Hospital ofÖrebro, Sweden

Introduction: Local anaesthetic wound infiltration is asimple and safe method for postoperative paintreatment.1 In this randomised placebo-controlled studythe effect of local levobupivacaine for 72 h onpostoperative pain after caesarean delivery wascompared to epidural analgesia.

Methods: 40 ASA physical status I-II parturients wereincluded after written informed consent. Before theoperation an epidural catheter was placed forpostoperative analgesia, and standard spinal anaesthesiawas administered. On completion of the operation, amultiorifice 20-gauge catheter was placed into thesurgical wound subfascially and connected to anelastometric balloon pump of 100 mL filled withlevobupivacaine or saline to facilitate nurse-controlledwound instillation. At the request for analgesia, 10 mLof 0.125% levobupivacaine was administered via theepidural route (EDA-group) and saline via the woundcatheter. The regional analgesia group (RA-group)received 10 mL of 0.25% levobupivacaine via thewound catheter and saline via the epidural route. Forsupplementary analgesia i.v. oxycodone (0.05 mg/kg)was administered. Pain and satisfaction scores wereassessed by an 11-point verbal rating scale (0-10).

Results: see table.Group EDA RA PMedian pain score 2 3Total dose of local

anaesthetic (mL) 89 92Supplementary opioid (n)

in recovery 14/20 19/20 0.09on ward 13/20 14/20 0.9

Total opioid dose (mg) 32 37 0.6Median satisfaction

with analgesia 8 7 0.2

Opioid-related side-effects were rare.

Conclusion: In this study the incisional localanaesthetic technique by a nurse-controlled drugdelivery system provided effective pain relief aftercaesarean delivery and was comparable in efficacy toepidural analgesia.

Reference1. Rawal N, Axelsson K, Hylander J, et al. Postoperative patient-

controlled local anesthetic administration at home. Anesth Analg1998; 86: 86-89.

O28 Dose-finding comparison of spinallevobupivacaine and bupivacaine forcaesarean section

K Khaw, WD Ngan Kee, F Ng, P LeungThe Chinese University of Hong Kong, Shatin, HongKong, China

Introduction: There are few clinical reports of usinglevobupivacaine for spinal anaesthesia, but a recentstudy suggested a lower potency when compared tobupivacaine for caesarean section.1 In this prospectiverandomised double-blinded dose-finding study, ouraims were to compare the potencies of levobupivacaineand bupivacaine, and to determine the optimum spinaldose regimens for caesarean section.

Methods: With Ethics Committee approval andinformed consent 120 ASA I-II women had electivecaesarean section under combined spinal-epiduralanaesthesia using an intrathecal dose of 5.5 mg, 6.5 mg,8 mg, 10 mg or 14 mg of either levobupivacaine orbupivacaine in 8% glucose. Sensory changes (ice andpinprick) and motor block (Bromage score) wereassessed every 2.5 min. Intraoperative pain was treatedwith 10-µg i.v. fentanyl boluses; if ineffective, theepidural catheter was topped up. An effective dose(success) was defined as a dose that provided adequatesensory dermatomal anaesthesia to pin prick to T7 orhigher, and required no epidural top-up for surgery tobe completed. The dose-response relationship wasdetermined using probit analysis. Groups werecompared using Student t-test, Mann-Whitney U-test,ANOVA and χ2 test. P <0.05 was consideredsignificant.

Results: Maternal and fetal demographics were similar.Onset rate of sensory anaesthesia and motor block weresimilar, but recovery from motor block was slower withbupivacaine over the dose range. Patients who receivedbupivacaine had a greater extent of motor block. TheED50 and ED95 values are shown in the table.

Dose in mg ED50 [95% CI] ED95 [95% CI]Levobupivacaine 9.3 [8.3-10.8], 13.6 [11.8-18.1]Bupivacaine 6.8 [5.7-7.6] 9.8 [8.7-13.1]

Conclusions: Levobupivacaine is 38% less potent thanbupivacaine when used intrathecally for caesareansection. For caesarean section, at least 10 mg ofbupivacaine and 14 mg of levobupivacaine will berequired in our patient population.

Reference1. Gautier P, De Kock M, Huberty L, Demir T, Izydorczic M,

Vanderick B: Comparison of the effects of intrathecal ropivacaine,levobupivacaine, and bupivacaine for Caesarean section. Br JAnaesth 2003; 91: 684-689.


O29 Randomised double-blind controlled trial ofropivacaine vs bupivacaine for extending low-dose epidural analgesia for emergencycaesarean section

RD Sanders, S Mallory, DN Lucas, TML Chan, S Yeo,SM YentisMagill Department of Anaesthesia, Chelsea &Westminster Hospital, London, UKIntroduction: A previous study suggested bupivacaine0.5% was more reliable than lidocaine 2% + adrenalineor a mixture for extending low-dose epidural analgesiafor emergency caesarean section.1 Ropivacaine’s lessertoxicity allows a higher concentration to be given forthe same degree of safety as bupivacaine. We thereforecompared 0.75% ropivacaine with 0.5% bupivacaine.Methods: After LREC approval, informed consent wasobtained from healthy primiparae receiving epiduralanalgesia (bupivacaine 0.1% 15 mL + fentanyl 2 µg/mLinitially, followed by 10 mL prn). If caesarean sectionfollowed, patients were randomised to receive 20 mL of0.75% epidural ropivacaine or 0.5% bupivacaine over 3min, in the tilted supine position, after 300-500 mLcrystalloid preload. Patients and observers were blindedto the group allocation. The primary outcome was timefrom end of injection to loss of cold sensation to T4.Cardiovascular variables, ephedrine/fluid requirements,need for supplementation of the block and Apgar scoreswere also recorded. A sequential analysis technique wasused with α 0.05 and β 0.2, based on a 30% reduction intime to T4 from previous studies.Results: Replacement of bupivacaine by l-bupivacainein our unit meant the study was stopped after 45patients (23 ropivacaine; 22 bupivacaine) had beenanalysed. Baseline data, reasons for surgery, duration ofepidural analgesia, number of top-ups and totalbupivacaine dose in labour were similar betweengroups. Time to loss of cold sensation to T4 was similar(Fig. 1) though variability appeared greater withbupivacaine. Supplementation/general anaesthesia wasrequired by 2/23 and 0/23 mothers respectively withropivacaine, compared with 9/22 and 1/22 withbupivacaine (P=0.01 [Fisher’s exact test]). Fluid andephedrine requirements and Apgar scores were similar.Fig. 1. Time to lossof cold sensation toT4 after 20 mLepidural ropivacaine0.75% or bupivacaine0.5%. Horizontallines indicatemedians.

0

10

20

30

40

50

Ropiv Bupiv

Tim

e(m

in)

Conclusion: That ropivacaine 0.75% appeared morereliable than bupivacaine 0.5% for the same degree ofsafety must be weighed against the fact that (i) 50% ofblocks reached T4 within 12 min in both groups, and(ii) l-bupivacaine 0.5% would be safer still. Furtherwork is needed to study the ideal drug for this situation.Reference1. Lucas DN, Ciccone GK, Yentis SM. Extending low dose epidural

analgesia for emergency Caesarean section. A comparison of threesolutions. Anaesthesia 1999; 54: 1173-1177.

O30 Effect of anaesthesia for caesarean section onneonatal acid-base status

F Reynolds, P Seed, LL PayDepartment of Anaesthesia, St Thomas’ Hospital andMaternal-Fetal Medicine Unit, Guys, Kings & StThomas’ School of Medicine, London, UK.

Introduction: Spinal is the most widely used methodof anaesthesia for caesarean section in the UK,1 and isgenerally considered both more practical and safer thanother techniques for the mother. Less attention has beenpaid to its effects on the newborn, although it is oftenassumed that because its haemodynamic effects neednot be adverse, its use must be acceptable from thebaby’s viewpoint. Although Apgar score is known to bedepressed by general anaesthesia, this is a short-livedand reversible effect, while umbilical artery (UA) acid-base status provides a better index of fetal welfare.

Method: Databases were searched for studies, bothrandomised and not, comparing neonatal acid-base datawith different types of anaesthesia for caesareansection. Three-way comparison of effect of anaesthesiatype: spinal-general (S-G), spinal-epidural (S-E) andepidural-general (E-G), on UA pH and base deficitvalues were conducted by random-effect meta-analysis.

Results: 19 studies were found reporting mean and SEor SD for UA pH, 14 of which included base excess(referred to here as deficit, to avoid negatives). Basedeficit values were significantly worse for spinal thanfor general or epidural anaesthesia (table). Results forsix of the studies that were randomised were similar,but did not reach significance.Table. Difference between umbilical artery acid-basevalues with types of anaesthesia for caesarean section

# Difference 95% CIpH S - G 14 -0.019 -0.040 to 0.003

S - E 9 -0.013 -0.027 to 0.001E - G 9 -0.007 -0.022 to 0.007S - G 7 1.109 0.434 to 1.784*Base

deficit S - E 7 0.910 0.222 to 1.598*E – G 6 0.269 -0.146 to 0.685

*P ≤0.01; # = number of studies

Conclusion: As UA pH is influenced by maternalrespiration, base deficit, although derived, is a betterindex of fetal metabolic acidosis. Recent meta-analysishas shown that the use of ephedrine (as in the majorityof studies included here) is associated with more severeUA acidosis than phenylephrine.2 More comparisonsare needed using other vasopressors. Meanwhile,mothers can be reassured that general anaesthesia doesnot cause more neonatal acidaemia than regionalanaesthesia.

References1. Thomas J, Paranjothy S. RCOG Clinical Effectiveness Support

Unit. The National Sentinel Caesarean Section Audit Report.London: RCOG press, 2001.

2. Lee A, Ngan Kee WD, Gin T. A quantitative systematic review ofrandomized controlled trials of ephedrine versus phenylephrine formanagement of hypotension during spinal anesthesia for cesareandelivery. Anesth Analg 2002; 94: 920-926.


O31 Comparison of maternal haemodynamiceffects and respiratory indices duringremifentanil and nitrous oxide labouranalgesia

P Volmanen,∗ E Akural,∗∗ T Raudaskoski,∗∗∗

S Alahuhta∗∗

∗Lapland Central Hospital, Rovaniemi, ∗∗Department ofAnaesthesiology, ∗∗∗Department of Obstetrics andGynaecology, University of Oulu, Finland

Introduction: Previously, we have observed thatremifentanil is superior to nitrous oxide (N2O) as alabour analgesic.1 The parameters related to maternalhaemodynamics and gas kinetics obtained during thesame study were analysed for this communication.

Method: After ethics approval, 20 parturientsparticipated in a prospective, randomised, double-blind,cross-over study. Intravenous remifentanil in 0.4 µg/kgPCA doses with one-minute infusion and lock-out timesand intermittent inhaled 50% N2O in oxygen werecompared during two 20-min study periods with a 20-min wash-out sequence after each period. Non-invasiveblood pressure was recorded at the end of each studyperiod. Heart rate pre min (HR), oxyhaemoglobinsaturation (SaO2), end-tidal carbon dioxide (ETCO2)and fraction of inhaled oxygen (FiO2) were recordedevery 10 s. Values recorded after the first PCA bolusfor each period were included in the analyses. ForFiO2, values recorded during the first PCA bolus werealso included. Averages of both study periods werecalculated for each parturient. Hypoxaemia andbradycardia were defined as SaO2<90% and HR<50,respectively, during >20 s. The Mann-Whitney test wasused for statistical analysis. P-value <0.05 wasconsidered significant.

Results: 15 parturients completed the study. There wasno period effect or treatment-period interaction. Thetreatment effects are summarized in the table. Onepatient had short (<1 min.) periods of bradycardiabefore and after the first dose of remifentanil. MeanSaO2 was lower during remifentanil. In two patientswith remifentanil and in one with N2O there was a short(>20 s, <1 min.) desaturation <95%, but no episode ofhypoxaemia was noted.

N2O Remifentanil PMAP, mmHg 96 (88-110) 96 (91-107) 0.3HR, beats/min 88 (75-90) 87 (79-96) 0.2ETCO2 , % 3.7 (3.5–3.9) 3.9 (3.2 – 4.3) 0.06SaO2 , % 98.8 (98.5-99.3) 98.0 (97.1–99.0) 0.001FiO2, % 48 (44-53) 47 (45-53) 0.7Data are median (25th - 75th percentiles).

Conclusion: This study suggests that remifentanil, inthe doses used here, has a mild depressant effect onrespiration. There were no differences inhaemodynamic parameters.

Reference1. Volmanen P, Akural E, Raudaskoski T, Alahuhta S. Comparison

of remifentanil and nitrous oxide in labour analgesia. ActaAnaesthesiol Scand 2001; 45: 2-7.

P01 Post cesarean section analgesia with continuouslocal infusion of ropivacaine or diclofenac

C Marbaix, F Roelants, V Mercier, H Waterloos,D Lacrosse, P Lavand’hommeDepartment of Anesthesiology, Université Catholiquede Louvain, 1200 Brussels, Belgium

Introduction: Analgesia after cesarean section isusually afforded by systemic opioids and NSAIDs.1

Wound irrigation with local anesthetic also is effective.2

Because surgical incision locally releases inflammatorymediators, the present study compares local infusion ofdiclofenac (D) or ropivacaine (Ropi) and i.v. D torelieve pain after cesarean section.

Methods: After informed consent, healthy parturientsscheduled for elective cesarean section under spinalanesthesia were randomly allocated to three groups. Atthe end of surgery, an elastometric pump was set todeliver a continuous subcutaneous infusion (5 mL/h for48 h) of either D 300 mg (n=19), Ropi 0.2% (n=18) orsaline (n=18). Patients in Ropi and saline groups alsoreceived i.v. D 75 mg every 12 h. All patients wereconnected to a PCA delivering i.v. morphine (M). Painscores (VAS 0-10) evaluated wound pain at rest and onmovement and pain from uterine contractions (C) 12,24 and 48 h after cesarean section. Morphineconsumption was also recorded. Statistical analysisused ANOVA, P <0.05 was considered significant.

Results: See Table. Demographic data were similar inthe three groups. No side effects were found.

Saline Ropi D12h 4±4.2 2±2.1 2±1.8VAS

rest 24h 3±2.4 2±2.1 1±1.348h 2±2.2 1±1.1 0±0.6*12h 7±1.9 3±2.9* 5±1.924h 6±2.8 5±2.2 4±1.6*

VASmove-ment 48h 4±2.6 3±1.4 2±2*

12h 1±1.1 2±2.4 2±2.824h 3±3.2 3±3.4 1±1.8*

VAScontrac-tions 48h 1±2.1 1±2.3 0±0.8M PCA 12h 21±14 11±9.8* 11±8.5*

(mg) 24h 28±7.1 16±3.3 13±2.5*48h 32±19 20±12 14±9*

*P <0.05 with saline

Conclusion: Local continuous infusion of D is moreefficient than systemic NSAIDs to relieve parietal andvisceral pain after cesarean section. Local ropivacaineis superior to D only during the first 12 h. The bestopioid-sparing effect is obtained with D infusion.

References1. Dahl V, Hagen IE, Sveen AM, Norseng H, Koss KS, Steen T.

High-dose diclofenac for postoperative analgesia after electivecaesarean section in regional anaesthesia. International Journal ofObstetric Anesthesia 2002; 11: 91-94.

2. Givens V, Lipscomb GH, Meyer NL. A randomized trial ofpostoperative wound irrigation with local anesthetic for pain aftercesarean delivery. Am J Obstet Gynecol 2002; 186: 1188-1191.


P02 Continuous wound irrigation with ropivacaineor diclofenac after cesarean section: immediateand delayed benefits

D Lacrosse, F Roelants, V Mercier, H Waterloos,P Lavand’hommeDepartment of Anesthesiology, Université Catholiquede Louvain, 1200 Brussels, Belgium

Introduction: Continuous wound irrigation with localanesthetic provides effective analgesia after cesareansection.1 Surgical injury locally releases inflammatorymediators such as prostaglandins, which sensitisenociceptors contributing to pain and hyperalgesia.However, results from wound infiltration with NSAIDsare inconclusive.2 This study compares immediate anddelayed benefits of continuous wound irrigation witheither diclofenac or ropivacaine.

Methods: After informed consent, healthy parturientsscheduled for elective cesarean section under spinalanesthesia were randomly allocated to three groups. Atthe end of surgery, an elastometric pump was set todeliver a continuous subcutaneous infusion (5 mL/h for48 h) of diclofenac 300 mg (n=19), ropivacaine 0.2%(n=18) or saline (n=18). Patients in the ropivacaine andsaline groups also received i.v. diclofenac 75 mg every12 h. All patients were connected to a PCA deliveringi.v. morphine (M) for 48 h. M consumption, hospitalstay, time before recovery (transit, stand up) and totalblood loss were recorded. Area of cutaneoushyperalgesia was measured at 24 h and 48 h with VonFrey filaments as well as percent of patients withhyperalgesia (PH). Residual pain (RP) at 1 and 6months was recorded. Statistical analysis used ANOVAand χ2; P ≤0.05 was considered significant.

Results: See Table. Demographic data, hospital stay,area of hyperalgesia and recovery parameters weresimilar in the three groups.

Saline Ropivacaine DiclofenacPH 24 h 50% 44% 31.5%PH 48 h 40% 22% 26%RP 1 month 40% 33% 5%*RP 6 months 22% 5.5% 0%*Total M use (mg) 32±19 19±12* 14±9 *

*P <0.05 compared with saline

Conclusion: Immediate benefits: local diclofenac wasmore effective than i.v. diclofenac and had an opioidsparing effect similar to local ropivacaine. Delayedbenefits: at 1 and 6 months, less residual pain waspresent after local diclofenac.References1. Dahl V, Hagen IE, Sveen AM, Norseng H, Koss KS, Steen T.

High-dose diclofenac for postoperative analgesia after electivecesarean section in regional anaesthesia. International Journal ofObstetric Anesthesia 2002; 11: 91-94.

2. Romsing J, Moiniche S, Ostergaard D, Dahl JB. Local infiltrationwith NSAIDs for postoperative analgesia: evidence for a peripheralanalgesic action. Acta Anaesthesiol Scand 2000; 44: 672-683.

P03 Dose-response study of epidural neostigminecombined with clonidine in early labor

E Malin, F Roelants, V Mercier, P Lavand’hommeDepartment of Anesthesiology, Université Catholiquede Louvain, 1200 Brussels, Belgium

Introduction: In early labor, epidural sufentanil 20 µgprovides analgesia without motor block. Neostigmine, acholinesterase inhibitor,1 and clonidine, an α2-adrenergic agonist, are also used during labor.Furthermore, analgesic interaction exists betweenspinal clonidine and neostigmine in human volunteers.2

This study assesses the efficacy of epidural clonidine75 µg combined with neostigmine (250 to 750 µg) toinitiate labor analgesia.

Methods: After informed consent, at the start of labor(cervical dilatation 3-5 cm), a lumbar epidural catheterwas inserted at L3-4 level in healthy parturients. WhenVAS (value 0-100) was ≥30, after a test dose, they wererandomly allocated to receive: sufentanil 20 µg (S20;n=22) or clonidine 75 µg with neostigmine 250 µg(CN250; n=12), 500 µg (CN500; n=18) or 750 µg(CN750; n=20) in a total volume of 12 mL. Pain score(VAS 0-100) at 5, 10, 15, 20 and 30 min, time torequest for supplemental epidural injection andropivacaine use throughout labor were assessed.Maternal and fetal vital signs, side effects and motorblock were also recorded. Statistical analysis usedANOVA; P <0.05 was considered significant.

Results: The four groups did not differ in demographicdata or initial VAS. Maternal and fetal vital signsremained stable. Analgesic efficiency (AE: percent ofparturients with VAS <30 at 10, 20, 30 min postinjection), duration of analgesia (mean±SD) andsubsequent ropivacaine use (mean±SD) are given in theTable. No motor block was recorded in any group.

S20 CN250 CN500 CN750AE 10 82% 46%*# 47%*# 78%AE 20 95% 46%*# 72.2% 84%AE 30 95% 50%*# 72.2% 84%Duration(min) 118±45 70±42* 92±50 91±52

Ropivacaine use(mg/h) 15.6±10 10.4±1.2* 10.2±2.7* 9.9±4.2*

*P <0.05 with S20; #with CN750

Conclusion: To initiate labor analgesia, epiduralclonidine 75 µg combined with neostigmine 750 µg isas effective as S20 in onset and duration, whereasCN250 does not provide satisfactory analgesia. Allepidural CN combinations produced a significantropivacaine-sparing effect.

References1. Roelants F, Rizzo M, Lavand’homme P. The effect of epidural

neostigmine combined with ropivacaine and sufentanil onneuraxial analgesia during labor. Anesth Analg 2003; 96: 1161-1166.

2. Hood DD, Mallak KA, Eisenach JC, Tong C. Interaction betweenintrathecal neostigmine and epidural clonidine in humanvolunteers. Anesthesiology 1996; 85: 315-325.


P04 Efficacy of epidural neostigmine combinedwith sufentanil or clonidine to initiate laboranalgesia

M Malisse, F Roelants, V Mercier, P Lavand’hommeDepartment of Anesthesiology, Université Catholiquede Louvain, 1200 Brussels, Belgium

Introduction: Epidural neostigmine, a cholinesteraseinhibitor, at a dose of 500 or 750 µg, combined withsufentanil has been shown to provide effective painrelief without motor block at the begin of labor.1

Clonidine, an α2-adrenergic agonist, is analgesic duringlabor (dose 60-100 µg) and spinal clonidine potentiatesneostigmine in human volunteers.2 This study comparesneostigmine combined with sufentanil or clonidine toinitiate labor analgesia.

Methods: After informed consent, at cervical dilatation3-5 cm, a lumbar epidural catheter was inserted at L3-4in healthy parturients. When the visual analogue painscore (VAS: 0-100) was ≥30, after a test dose, theywere randomly allocated to receive: sufentanil 10 µgwith neostigmine 500 µg (S10N500; n=25) or 750 µg(S10N750; n=25) or with clonidine 75 µg (S10Clo75;n=18). Clonidine 75 µg was combined withneostigmine 500 µg (N500Clo75; n=18) or 750 µg(N750Clo75; n=20) in a total volume of 12 mL. VAS at5, 10, 15 and 30 min, and time to request forsupplemental epidural dose were assessed. Maternaland fetal vital signs, side effects and motor block werealso recorded. Statistical analysis used ANOVA; P<0.05 was significant.

Results: Demographic data and initial VAS did notdiffer between groups. Maternal and fetal signsremained stable. Analgesia efficiency (AE: percent ofparturients with VAS <30 at 5, 10, 15 and 30 min postinjection) and duration of analgesia (mean±SD) areexpressed in the Table. No motor block was recorded.

S10N500

S10N750

S10Clo75

N500Clo75

N750Clo75

AE 5AE 10AE 15AE 30Duration

60%72%76%92%

55%64%65%72%

59%65%59%88%

38,5%47%*#61,1%*

72%

64%78%87%84%

(min) 118 ± 29 102 ± 41 92 ± 47 92 ± 50 91 ± 52*P <0.05 with S10N500; # with N750Clo75

Conclusion: At the start of labor, N500 combined withClo75 has significantly slower onset than with S10. Toinitiate epidural analgesia, the best combination isN750Clo75. After 30 min, all combinations displaysimilar efficacy. All groups show similar duration ofanalgesia without motor block or side effects.

References1. Roelants F, Lavand’homme P. Epidural neostigmine combined

with sufentanil provides balanced and selective analgesia in earlylabor. Anesthesiology, in Press

2. Hood DD, Mallak KA, Eisenach JC, Tong C. Interaction betweenintrathecal neostigmine and epidural clonidine in humanvolunteers. Anesthesiology 1996; 85: 315-325.

P05 Combined spinal-epidural analgesia forlabour and the effect of epidural volumeextension

V Pandit, P Sajith, S Chitre, J Crowhurst, GM StocksQueen Charlotte’s &Chelsea Hospital, London, UK

Introduction: The technique of combined spinal-epidural (CSE) for labour provides rapid and reliableanalgesia. Initially however, some women notice adegree of lower limb and pelvic floor motor block.With epidural volume extension (EVE), normal salineis injected into the epidural space immediately afterintrathecal injection and may extend spinal analgesia.1

Preliminary observations in our unit suggest that EVEmay reduce lower limb and pelvic floor motor block.The aim of this study was to investigate these possibleeffects and the effect of EVE on analgesia onset time.

Methods: After written informed consent, 39 womenrequesting analgesia for labour between 2-6 cm ofcervical dilatation were randomised into two groups toreceive CSE analgesia using a needle-through-needletechnique with or without EVE. Both groups receivedan intrathecal dose of bupivacaine 2.5 mg and fentanyl25 µg. Those allocated to the EVE group received 7 mL0.9%w/v saline via the epidural needle immediatelyafter the intrathecal dose. Pain was assessed usingvisual analogue pain scores (VAPS), until effectivepain relief was obtained, defined as a VAPS score <10mm after 15 min. Motor block was assessed at 10, 20and 30 min with reference to specific myotomesbetween L1 and S1. A score of 0 was assigned for noblock, 1 for partial block and 2 for complete block.Pelvic floor tone was also assessed verbally.

Results: Patient and obstetric characteristics weresimilar in the two groups. In the EVE group, there wasa significantly larger number of women who hadnormal pelvic floor tone at 10 and 20 min (Table).

Group (n) Pelvic tone intactat 20 min*

Contractions (n)before analgesiaMean (95% CI)

Control (20) 4 1.35 (0.85,1.85)EVE (19) 10 2.30 (1.58,3.05)

∗ χ2 P <0.05At 30 min, however, no significant difference wasfound. Although not statistically significant, there was atendency to less lower limb motor block in the EVEgroup at 10 and 20 min but not at 30 min. In bothgroups analgesia was achieved quickly but, althoughnot statistically significant, there was a tendency toslower onset of analgesia in the EVE group (table).Conclusion: The use of EVE with CSE for labour mayreduce lower limb and pelvic floor motor block initiallycompared to no EVE but this does not appear to be asustained effect. This effect on motor block may be atthe expense of a slower onset of analgesia.Reference1. Takiguchi T, Okano T, Egawa H, Okubo Y, Saito K, Kitajima T.

The effect of epidural saline injection on analgesic level duringcombined spinal and epidural anesthesia assessed clinically andmyelographically. Anesth Analg 1997; 85: 1097-1100.


P06 Patient-controlled epidural analgesia (PCEA)during labor: a comparison of basal rates

C Grubb, P Balestrieri, C Lin, P TingDepartment of Anesthesiology, University of VirginiaHealth System, Charlottesville, Virginia, USA

Introduction: PCEA reduces anesthetic consumptionand anesthesiologist interventions,1 yet the need for andbenefit of a basal rate (BR) in PCEA regimens arecontroversial. Many studies have compared low BRs(3-5 mL/h) with no BR, finding no difference inanalgesia. These studies conclude BRs should beavoided, as they only increase side effects.2 No one hasevaluated high BRs, nor measured anesthesiologistsatisfaction. Our prospective, double blind trialcompared BRs in labor PCEA.

Methods: After institutional review board approval,laboring patients randomly received PCEA regimensconsisting of 125% bupivacaine with fentanyl 2 µg/mLwith one of three BRs: 10, 4, or 0 mL/h. The otherPCEA features were the same for all: 5-mL demanddoses up to every 5 min with a 30-mL/h maximum.When additional analgesia was requested, the blindedanesthetist administered 5-mL top-up boluses of 0.25%bupivacaine. Patient and anesthesiologist satisfactionscores (10-cm VAS), number of top-ups required, andside effects were recorded, including motor blockade.Student t-test and χ2 analyses were used as appropriate.

Results: We enrolled 24 patients (8/group). Patient andprovider satisfaction were similar between groups.Number of top-ups required was also equal. Yet, bothBR groups had more drug consumption than the no BRgroup. Pruritus was the most common side effect in allgroups, with no differences between basal rateassignments. Little motor block occurred in this study,with no differences between groups. When short labors(<150 min) were excluded, results again remainedsimilar except for hourly bupivacaine usage.

0 mL/h 4 mL/h 10 mL/hPatient satisfaction (%) 93.6 93.8 93.1Provider satisfaction (%) 87.7 82.5 84.9Bupivacaine (mg/h) 1.1* 3.0 2.4

Data are means; *P <0.03 for both BR comparisons

Conclusion: Few differences were found between ourBR groups. PCEA with no BR resulted in reduced drugconsumption, but did not translate into reductions inside effects or motor weakness. However, our studywas not powered to detect small differences in sideeffects. Regardless, higher BRs were not harmful, butdid not increase patient or anesthetist satisfaction.Future studies should examine PCEA regimens with alower opioid content to further reduce side effects.References1. Van der Vyver M, Halpern S, Joseph G. Patient-controlled epidural

analgesia versus continuous infusion for labour analgesia: a meta-analysis. Br J Anaesth 2002; 89: 459-465.

2. Wong K, Chong J, Lo W, Sia A. A comparison of patient-controlled epidural analgesia following gynaecological surgerywith and without a background infusion. Anaesthesia 2000; 55:212-216.

P07 Patient controlled intravenous alfentaniladministration during elective caesarean sectionunder subarachnoid anaesthesia: effects ofintrathecal fentanyl on analgesic requirements

KN Litchfield, NL Purdie, GNC Kenny, EM McGradyUniversity and NHS Departments of Anaesthesia,Glasgow Royal Infirmary, Glasgow, UK

Introduction: In the UK, spinal anaesthesia is theanaesthesia of choice for elective caesarean section.1

Despite adequate sensory block, visceral abdominalpain during surgery is common with 12-24% requiringsupplemental analgesia.2,3 Intrathecal opioids canreduce the incidence of visceral pain.3 PCA alfentanil isan effective method of administrating supplementalanalgesia.4 We proposed to use PCA alfentanil as i.v.opioid supplementation to quantify the effect ofintrathecal (IT) fentanyl for elective caesarean section.

Method: Following local research ethics committeeapproval and written informed consent 60 healthywomen with singleton term pregnancies scheduled forcaesarean section were recruited. Patients wererandomised to receive hyperbaric bupivacaine 12.5 mgwith saline 0.2 mL (group S) or fentanyl 10 µg (groupF). PCA alfentanil was set to deliver a 3-µg/kg bolusthen subsequent 1.5-µg/kg doses with a 2-min lockout.Data were analysed with Mann-Whitney rank sum test,Students t test and z-test for proportions.

Results: There were no differences between the groupsin age, BMI, parity, gestation, block height, length ofsurgery, ephedrine use, Apgar score or UV pH.

Table 1. VAS and PCA alfentanilGroup S

n=28Group F

n=30P-

valueVAS >30mm (n) 6 (29) 5 (17) 0.44Number using PCA 10 (38) 6 (20) 0.24Alfentanil (µg) 285 [520] 121 [300] 0.3

Values are n (%) or mean [SD]

Conclusion: The incidence of moderate to severevisceral discomfort and the use of supplementalanalgesia was reduced in the IT fentanyl group, andalthough this did not reach statistical significance it isprobably clinically significant.References1. Shibli KU, Russell IF. A survey of anaesthetic techniques used for

caesarean section in the UK in 1997. International Journal ofObstetric Anesthesia 2000; 9: 160-167.

2. Garry M, Davies S. Failure of regional blockade for caesareansection. International Journal of Obstetric Anesthesia 2002; 11: 9-12.

3. Dahl J B, Jeppesen H, Wetterslev J, Moiniche S. Intraoperativeand postoperative analgesic efficacy and adverse effects ofintrathecal opioids in patients undergoing cesarean section withspinal anesthesia: a qualitative and quantitative systematic reviewof randomised controlled trials. Anesthesiology 1999; 91: 1919-1927.

4. Purdie N L, Kenny G N C, McGrady E M. patient controlledadministration of intravenous alfentanil during elective caesareansection under subarachnoid anaesthesia. International Journal ofObstetric Anesthesia 2003; 12: 169-172.


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P08 Sufentanil 5 µg and clonidine 75 µg have asimilar effect on the MLAC of ropivacaine inlabour

JP Galeazzi, N Janssens, J-C Thiry, V Bonhomme,PY Dewandre, P Hans, JF BrichantService Universitaire d'Anesthésie-Réanimation, CHR de laCitadelle, Université de Liège, Liège, Belgium

Introduction: The addition of opioids or α2-adrenergicagonists to local anaesthetics improves obstetric epiduralanalgesia and reduces dose requirement and motor block.This study compares the effects of the addition of sufentanil5 µg or clonidine 75 µg on the minimum local analgesicconcentration (MLAC) of ropivacaine.

Material and methods: With their consent, 48 parturientspresenting at cervical dilatation 1-5 cm, with visualanalogue pain score (VAS) >7/10 and requesting epiduralanalgesia, were studied. After epidural catheter insertion,ropivacaine 20 mL with sufentanil 5 µg (n=25) or clonidine75 µg (n=23) was administered. The first ropivacaineconcentration used was 0.1% and subsequent concentrationsof ropivacaine were determined by the response of theprevious patient in that group, using up/down sequentialallocation and a testing interval of 0.01%. A VAS ≤1 cmwithin 30 min after epidural bolus was considered effective.MLAC represents the median of the concentrations ofropivacaine used in each group. Confidence intervals (CI)were calculated according to the equation:CI= MLAC±1.95×standard deviation of the median. Forpower calculation, α value was set at 0.05.Results: Demographic, obstetric and haemodynamic datawere similar in the two groups. The MLAC of ropivacainewas 0.04% (95% CI: 0.030-0.050) in the sufentanil groupand 0.04% (95% CI: 0.029-0.051) in the clonidine group.The power of the study was 90%.

: ropivacaine+sufentanil, effective/ineffective;×∗ ropivacaine+clonidine, effective/ineffective;line: MLAC ± 95% CI.Conclusion: Previous studies found MLAC values forropivacaine of 0.097-0.156% when given alone forlabour analgesia. Our data suggest that the addition ofsufentanil 5 µg or clonidine 75 µg is equally effectivein reducing ropivacaine MLAC. This is important whencomparing the side effects of the addition of these twodrugs to epidural local anaesthetics for labour analgesia.

P09 The International Journal of ObstetricAnesthesia – oft cited yet not indexed

R Davies,* SM Yentis* and R Wentz†

*Magill Department of Anaesthesia and †MedicalLibrary, Chelsea & Westminster Hospital & ImperialCollege, London, UK

Introduction: The International Journal of ObstetricAnesthesia (IJOA) is ranked 13th according to the 2002impact factors for anaesthetic journals,1 but is the onlyone of the top 20 not to be indexed on MEDLINE. Wewished to assess IJOA’s importance despite this, byseeing from which journals papers on obstetricanaesthesia were most frequently cited over the last fivecompleted years.

Method: We searched the internet-based Web ofKnowledge database1 for the 50 most commonly citedpapers for the years 1997-2002 that matched the searchcriteria (cesar* OR caesar*) AND (anest* OR anaest* ORepidural OR spinal OR subarachnoid* OR intra-thecal*OR intrathecal* OR peridural OR extra-dural ORextradural), restricted to title.

Results: Retrieved articles 49-56 each had the samenumber of citations, so a total of 56 articles wereanalysed. The articles came from 12 journals (Table),of which IJOA was the only one not listed in MEDLINE.Table. No. (%) of cited articles per journal.

Anesthesia & Analgesia 18 (32%)Anesthesiology 12(21%)IJOA 5 (9%)British Journal of Anaesthesia 4 (7%)Anaesthesia 4 (7%)Regional Anesthesia & Pain Medicine 3 (5%)Canadian Journal of Anaesthesia 2 (4%)American Journal of Obs. & Gynecology 2 (4%)Anaesthetist 2 (4%)Acta Anaesthesiologica Scandanavica 2 (4%)Neuro-report 1 (2%)Obstetrics & Gynecology 1 (2%)

Discussion: Within our limited search criteria, IJOAwas the third most commonly cited source of articlesrelating to caesarean section and regional anaesthesia.This fact alone should support IJOA’s inclusion inMEDLINE; furthermore, we propose that if IJOA wasindexed, it would be cited even more often, and for it tocontinue to be overlooked deprives researchers andpatients of relevant knowledge in this area of practice.

Conflict of interest: SY is Hon. Secretary of theObstetric Anaesthetists’ Association (which has IJOAas its official journal), and an Editorial Board memberof IJOA.

Reference1. ISI Web of Knowledge. http://wok.mimas.ac.uk/ (accessed

2/1/2004).


P10 The morbidly obese parturient – anaestheticmanagement and maternal and fetal outcomes

D Mullhi, G Kelly, U Dandekar, N OsbornDepartment of Anaesthesia, Heartlands Hospital,Birmingham, UK

Introduction: The morbidly obese parturient presentsnumerous challenges. Studies have shown an increasedincidence of gestational diabetes, preeclampsia, greaterinfant birth weight and more postoperative woundinfections and thromboembolic events in this patientgroup.1-3 In addition, operative delivery is morecommon. There are implications for patient handling,equipment, and anaesthesia, as anaesthetic interventionis more likely and may be problematic. There was aperception at our hospital that we were seeing anincreasing number of morbidly obese parturients, butthis had not been formally assessed.

Method: Case-notes of all parturients with a bookingBMI >40 kg/m2 who delivered at Heartlands NHS Trustbetween Jan and Sept 2003 were reviewedretrospectively. Data were collected to quantify thedegree of anaesthetic involvement and to assessmaternal and fetal outcomes and are presented asmedian and range unless otherwise stated.

Results: Fifty-two case notes were reviewed. Meanmaternal age was 30 years. Median BMI was 42 kg/m2

(40-57). In only three cases were the obstetricanaesthetists informed during the antenatal period.Seven women developed hypertension, two developedpreeclampsia, 28 were delivered vaginally and 24 bycaesarean section (10 elective and 14 emergency).Thirty-four deliveries occurred outside office hours.

Anaesthetic Involvement:Total Difficult Failed

Epidurals 5 2* 3Spinals 14 7 2CSE 3 2 0

*one woman developed an epidural haematoma

Neonatal outcome: weight 3.5 kg (2.46-4.73), Apgarscores 8 (0-9) and 9 (4-10) at 1 and 5 min. There weretwo intrauterine deaths.

Discussion: Morbid obesity in the peri-partum period isa significant concern in our obstetric unit. Between Janand Sept 2003, 65 women had a booking BMI ofgreater than 40 kg/m2 (2% of all deliveries). Followingthis study, we are instituting multi-disciplinaryguidelines for the management of these patients,covering antenatal anaesthetic referral, appropriateinduction times and senior supervision of trainees.References1. Hunter J D, Reid C, Noble D. Anaesthetic management of the

morbidly obese patient. Hospital Medicine 1998; 59: 481-482.2. Garbaciak J A, Richter M, Miller S, Barton J J. Maternal weight

and pregnancy complications. Am J Obstet Gynecol 1985; 152:238-243.

3. Hood D, Dewan D. Anesthetic and obstetric outcome in morbidlyobese parturients. Anesthesiology 1993; 79: 1210-1218.

P11 Obesity, pregnancy and anaesthesia in adistrict general hospital

M Rupasinghe, L McLoughlinDepartment of Anaesthesia, Colchester GeneralHospital, Essex, UK.

Introduction: There is concern at the rising level ofobesity in the UK population.1 Evidence suggests anadverse effect of maternal obesity on obstetric andanaesthetic outcome.2 Furthermore, concerns fromlabour ward staff regarding possible Health and Safetyissues when dealing with an anecdotally more obesepatient population prompted us to investigate theimpact of obesity on our labour ward anaestheticpractice in a district general hospital.

Method: Data were collected prospectively on allpregnant women undergoing anaesthetic interventionon the labour ward during a ten-month period. Obesitywas defined as BMI >30 kg/m2.

Results: Complete data were available for 621 of 974parturients.• Average antenatal booking weight 66.4 kg• 15% of women had BMI >30kg/m2

• 60% of all anaesthetic interventions were forregional labour analgesia

• 12% of those having epidural analgesia were obese• 67% of obese women having anaesthetic

intervention had caesarean section• Obese parturients were not over-represented in

overall caesarean section rates (19%), eitherelective (18%) or emergency (20%)

• 27% of those with epidural analgesia requiredemergency caesarean section.

Obese Non-obese>1 attempt to locate epidural space 16% 7%Epidural re-sited 9% 2%Total epidural failure 2% 0.6%Obvious dural tap 7% 0.6%Emergency caesarean section 38% 24%Conversion to general anaesthesia 17% 15%

There were no problems related to obesity and generalanaesthesia.

Conclusions: Our evidence suggests that obese womenare more likely to experience problems with regionalanalgesia in labour than non-obese women and to haveless favourable obstetric outcomes from bothanaesthetic and obstetric interventions. The relativelysmall number of obese women in our study mightexaggerate these differences and preclude statisticalinterpretation until further data are collected. This studyis ongoing.

References1. Offer A. Body weight and self control in the United States and

Britain since the 1950s. Social History of Medicine 2001; 14: 79-106.

2. Bongain A, Isnard V, Gillet JY. Obesity in obstetrics andgynaecology. Eur J Obstet Gynecol Reprod Biol 1998; 77: 217-228.


P12 Is routine use of combined spinal epiduralanaesthesia for all caesarean sectionsjustified?

N Walton, S Nikolic, R SashidharanThe Royal London Hospital, London, UK

Introduction: Combined spinal-epidural (CSE) is awell-recognised technique for providing anaesthesia forcaesarean section.1 Its advantages include the reliabilityof the spinal block and the flexibility of the epidural,enabling it to be extended or prolonged. On the otherhand it potentially exposes the patient to morecomplications than either alone. These includeinadequacy and failure of the spinal component.2

Method: For 4 months, we prospectively audited all denovo regional anaesthetics conducted for caesareansection. We reviewed complications associated with theprocedure and the reasons for using the epiduralcomponent. During a part of this period we weresimultaneously conducting a research study involvingCSEs where the study design included the use of theepidural component.

Results: Of the total 261 caesarean sections, 146 had denovo regional anaesthesia. Of these 71 (48.6%) hadCSE and 75 (51.4%) single shot spinals. Seven in theCSE group were involved in the simultaneous study.All except the study group received bupivacaine 10 mgand diamorphine 250 µg intrathecally.

CSE (n=71) Spinal (n=75)Bloody tap 3 -Difficulty siting spinal 3 -Inadequate block height 2 -Pain / discomfort 9 1(Needing GA) (0) (1)Overall complications 17 (23.9%) 1 (1.3%)

Discussion: Compared to 15.5% among the CSEs, only1.3% in the spinals had inadequate analgesia from thesubarachnoid block. In 12 CSEs, the epidural wastopped up due to prolonged surgical time, which wasanticipated and in one other woman with a history ofcystic fibrosis, it was used for postoperative analgesia.In 40 CSEs (56.3%), the epidural was never used. Inseven (9.9%) it was used only for research purposes. In11 (15.4%) the CSE itself may have contributed to theinadequacy of the spinal component. Is it good practiceto subject women to a more complicated procedure withincreased risks and side effects, in order to avoid anuncommon problem or to participate in a study? CSEhas proven to be a versatile technique and definitely hasa useful place in obstetric anaesthesia, but its use shouldbe tailored to the individual and the risks and benefitsconsidered rather than be used as a routine technique.

References1. Shibli KU, Russell IF. A survey of anaesthetic techniques used for

caesarean section in the UK in 1997. International Journal ofObstetric Anesthesia 2000; 9: 160-167.

2. Levy N, Fernando R. Reducing the incidence of technical failuresand paraesthesia in combined spinal-epidural techniques.Anaesthesia 2000; 55: 1230-1231.

P13 Improving the efficiency of elective caesareansection operating lists

J Bell, H Wise, M WeeDepartment of Anaesthesia, Poole Hospital NHS Trust,Longfleet Road, Poole, Dorset, UK

Introduction: Elective and emergency caesareansection rates are rising.1-3 Many obstetric theatrescombine emergency and elective workload. Delays instart and finish times of elective caesarean sectionoperating lists may have a negative impact on patientcare and staffing levels in both obstetric and anaestheticdepartments.

Method: A three-month audit was carried out to elicitthe frequency and causes of inefficiencies in electivecaesarean section lists. Subsequent changes in practicewere made to attempt to improve theatre efficiency andthe audit was repeated the following year.

Results:Audit 1 Audit 2

Number of days audited 48 41Data coverage 87.5% 85%Elective caesarean section (n) 66 69List start on time 19% 61%Patients ready for theatre 53% 84%Turnaround <20mins 26% 16%Emergency interruptions 25% 52%2 obstetricians available 50% 86%2 anaesthetists available 94% 94%2 ODAs available 86%* 39%*2 midwifery teams available ?* 94%

* Incomplete data

Conclusion: Elective theatre efficiency depends onprompt start and finish times, good communication,adequate staff and robust policies and protocols.4 Someaspects of obstetric elective theatre efficiency may beimproved by the completion of a simple audit cycle.Improved data collection may further increase theimpact of the audit.

References1. Thomas J, Paranjothy S. Royal College of Obstetricians and

Gynaecologists Clinical Effectiveness Support Unit. NationalSentinel Caesarean section report. London: RCOG Press, 2001.

2. May AE, Yentis SM. Up, up and away: watching the Caesareansection rate rise. Anaesthesia 2002; 57: 317-318.

3. Jenkins JG, Khan MM. Anaesthesia for Caesarean section: asurvey in a UK region from 1992 to 2002. Anaesthesia 2003; 58:1114-1118.

4. Association of Anaesthetists of Great Britain and Ireland. TheatreEfficiency: Safety, quality of care and optimal use of resources.London: AAGBI, 2003.


P14 Regional anaesthesia for caesarean section:communication of risk and patient satisfaction

DA Varveris, A MacFarlane, NG Smart*Southern Genera1 and *Glasgow Royal Infirmary, UK

Introduction: Discussing risk is an essential part ofinforming patients about anaesthesia and is nowenshrined in the Department of Health guidance onconsent,1 although not all patients want to know aboutrisk because it frightens them.2 Patient satisfaction is animportant measure of quality of care that can contributeto a balanced evaluation of the entire process.3 The aimof this study was to examine to what extent patientswished to be informed of risk and whether they weresatisfied with the information received.

Methods: 60 patients, ASA I–II, undergoing electivecaesarean section were recruited prospectively. Datacollection included age, ASA status and previousepidural or subarachnoid block. Communication of riskand attitudes to certain specific risks were examinedand patient satisfaction assessed using a graded verbalrating. Descriptive statistics were derived for the studypopulation and are expressed as percentages.

Results: The response rate was 88.3%; 16.9% were <25years of age, 60.3% 26-35 years, and 24.5% >35.Modal ASA I. The risks and benefits of regionalanaesthesia were not explained in 17% and partlyexplained in 6%. Nonetheless, 70.3% were verysatisfied with the explanation of risk while a further26.1% were quite satisfied. Responses regardingspecific risks are summarised in the table.Table: How important would it be to you to be made aware ofthe possibility of: a) permanent nerve injury [PNI], b)temporary continuing numbness, c) block failure? (Expressedas percentages, n =54)

V. important important neither unimportantPNI 40.1 42.5 14.1 3.3Numbness 29.6 33.3 16.6 20.5Block failure 53.8 34.6 9.6 2.0

Conclusions: The majority of respondents wanted to bemade aware of the risks associated with regionalanaesthesia for elective caesarean section. Nevertheless,a range of needs for risk information was demonstrated,suggesting the extent to which risks should be disclosedis also a matter of clinical judgement. This may explainthe apparent discrepancy between high satisfaction withexplanation of risk and high incidence of episodeswhere risk was either partly explained or not explained.

References1. Reference guide to consent for examination or treatment.

London: Department of Health, 2001.2. Smart NG, Varveris DA. Communication of risk. European

Journal of Anaesthesia 2002; 19, Supplement 24: 10.3. Donabedian A. The quality of care. How can it be assessed?

JAMA 1988; 260: 1743-1748.

P15 The use of sodium citrate for acid aspirationprophylaxis in elective caesarean section

M K Doddi, B H HeidemannRoyal Infirmary, Edinburgh, UK

Introduction: Pre-medication to reduce the acidity ofgastric contents is regarded as an important part ofobstetric anaesthetic practice.1 Even in patientsundergoing caesarean section under regionalanaesthesia antacid prophylaxis is consideredobligatory2 and is part of the local protocol. Whilstantacids may not reduce the risk of vomiting, they maydecrease the sequelae of aspiration of gastric contents.We were interested in the current practice in our unitwith regards to the use of sodium citrate.

Methods: Over a four-week period we audited the useof antacid pre-medication in elective caesareansections. We recorded whether antacids wereprescribed, correctly administered and associated withany side effects.

Results: Thirty-five patients were audited, all of whomreceived spinal anaesthesia for elective caesareansection. Conversion to general anaesthesia was notrequired in any of the cases. Only three patientsreceived 0.3 M sodium citrate 30 mL by mouth inaddition to ranitidine 150 mg by mouth pre-operatively.Two of these suffered from nausea and vomiting beforethe onset of spinal blockade, but only one patientreceived ranitidine following the onset of spinalblockade. Of the three patients with a history of refluxonly one received sodium citrate. There was noevidence of aspiration of gastric contents in any patient.

Discussion: Whilst the use of a combination ofranitidine and 0.3 M sodium citrate is recommended3

and part of the local protocol, most patients undergoingelective caesarean section receive ranitidine only.Protocol adherence in our unit is poor and the reasonsfor this deserve further investigation. The highincidence of nausea and vomiting in those receiving0.3 M sodium citrate may provide one explanation forour observations, as it might seem inappropriate to usean antacid to prevent aspiration if this results in nauseaand vomiting. Furthermore, as the rate of conversionfrom regional to general anaesthesia is extremely low,the need for using two agents to control gastric pH mayno longer be perceived.

References1. Burgess GE, 3rd. Antacids for obstetric patients. Am J Obstet

Gynecol 1975; 123: 577-559.2. Stonell C. The awake patient can aspirate. International Journal

of Obstetric Anesthesia 2000; 9: 213.3. Gillett GB, Watson JD, Langford RM. Ranitidine and single-

dose antacid therapy as prophylaxis against acid aspirationsyndrome in obstetric practice. Anaesthesia 1984; 39: 638-644.


P16 Haematocrit as a predictor of arterialhypotension during spinal anaesthesia inpreeclamptic parturients

EM Shifman, GV FilippovitchRepublican Perinatal Center, Ministry of Health,Petrozavodsk, RussiaIntroduction: The occurrence of arterial hypotensionduring caesarean section under spinal anaesthesia inpreeclamptic parturients depends much on initial fluidstatus. Measuring the haematocrit is an important partof pre-operative intravascular volume assessment. Thegoal of the study was to estimate the dependencebetween initial haematocrit and frequency of arterialhypotension during caesarean section under spinalanaesthesia in preeclamptic parturients.Method: We performed a retrospective observationalstudy of 54 caesarean sections under spinal anaesthesiain preeclamptic parturients. The haematocrit wasdetermined before intervention for each patient. Weused 0.5% isobaric bupivacaine for spinal block. Duralpuncture was performed in L2-3 or L3-4 interspaces inthe sitting position under standard haemodynamicmonitoring. Blood pressure was measured every 2 minbefore delivery and then every 5 min before transferringthe parturient to the recovery room. Hypotension wasdefined as a decrease in systolic arterial pressure morethan 20% of baseline values. Those with a tendency toarterial hypotension received an infusion of 6%pentastarch. All results of monitoring were analysedusing t-test with P <0.01.Results: The average decrease in systolic arterialpressure in the tested group during spinal anaesthesiawas not critical; no-one showed clinically significanthypotension that could be considered a complication ofanaesthesia. Vasopressors were not used. The baselinehaematocrit values in those with and without a tendencyto hypotension are shown in the table. The differencebetween the two groups was significant (P <0.01).Table 1. Difference in haematocrit baseline values betweentwo groups of parturients (without hypotension and withtendency to hypotension, decrease in systolic arterial pressure≥20% of baseline values)

Baseline haematocrit (%)

Parturients n Mean Standarddeviation Median

With tendency forhypotension

39 34.3 0.39 34

Withouthypotension

15 31.7 0.61 32

Conclusion: Haematocrit can be an important predictorof arterial hypotension developing as a complication ofspinal anaesthesia. If the haematocrit is ≥35%,individually optimised haemodilution should beadministered in pre-operative phase. Prophylactic 6%pentastarch solution infusion is recommended duringspinal anaesthesia to prevent arterial hypotension.

P17 National survey of anaesthetic obstetrictrainee rotas

E Kam, F DoddDepartment of Anaesthesia, Wythenshawe Hospital,Manchester, UK

Introduction: Historically, obstetric anaesthesiatrainees have worked a 24-hour on-call pattern. Theimportant teaching and training are undertaken duringthe day when there are dedicated consultant sessions,and the trainees cover the out of hours emergencies andepidural requests. Working patterns are to change.1 The‘new deal’ came into operation in August 2003 andnow the European working time directive [EWTD]starts in August 2004. All trainees will be on amaximum 13-hour full shift, with a 48-hour weekimplemented by 2009. In most units this will result in areduction of day time training. The task forces haverecommended that for a full shift to be successful, itrequires at least eight individuals, and the Departmentof Health recommends planning should start 18 monthsin advance. We wanted to see what the nationalawareness was of this enormous and imminentproblem.

Method: A questionnaire was sent to all 294 collegetutors, asking about the number and nature of all traineerotas in their hospital. It also asked what provision theirhospitals and departments had made for theimplementation of the EWTD and what they felt theeffect would be on training. The data were collected byMarch 2003.

Results: The response rate was 45% and 89 maternityrotas were identified, 76% covering maternity only;47% of trainees worked a 24-hour pattern, 32% apartial shift and 21% a full shift. The average numberof trainees on these rotas was only five; 58% ofanaesthetic departments had virtually no plans forAugust 2004. All tutors expressed anxiety regardingtraining with the EWTD on all rota patterns of less thanseven individuals (although no rota had more thanseven!) Tutors thought the only solutions were toincrease staffing levels, to decrease the out of hourswork or to centralise acute services, none of which arerealistic options in the short term.

Conclusion: A depressing result for such an importanttopic. It is possible to merge doctors into ‘emergency ‘or ‘acute’ teams out of hours, but we feel anaesthetistshave such specific and life saving skills that it will bedifficult to reduce their presence in hospital out ofhours, especially for the high risk speciality ofmaternity. We know that several pilot studies areongoing examining changing working practice and thatthe Royal College of Anaesthetists have recentlyundertaken an extensive manpower survey. We awaitthe results with interest.

Reference1. Hutton P. The doomsday scenario. Royal College of Anaesthetists’

Bulletin 2001; 9: 400.


P18 Acceptability of an epidural information cardNA Barrett, HR Jones, A. Kalbag, SM Yentis,J Durbridge, M Cox, MYK Wee*Magill Department of Anaesthesia, Chelsea &Westminster Hospital, London and *Poole GeneralHospital, UK

Introduction: We modified an existing epiduralinformation card1 that describes epidural insertion andbenefits, by adding risk information to the reverse side.After introducing the card in our unit, we assessed itsacceptability and value ante and post partum.

Methods: After ethics committee approval, 40 womenwere given the card to read: 20 in the antenatal clinic at30-38 weeks and 20 in early labour. In the latter groupthe attending anaesthetist gave his/her usual talk beforeepidural siting when requested. Women’s opinionswere recorded, either in the clinic or post partumrespectively, using visual analogue scores for the valueof the explanation of epidurals generally, the risks inparticular and whether this information worried them.They were also asked when they thought was the besttime for receiving the card and for any other comments.

Results: Overall both groups of women found the cardinformative and non-worrying (Table).

Table. Visual analogue scores given by women forthe value of the information given ante partum(Ante) or post partum (Post). Data are median(interquartile range [range]).

Ante Post

Explanation of epidurals 8(7-8 [0-10])

8(7-9 [5-10])

Explanation of risks 7.5(7-8 [0-10])

8(7.5-8.5 [5-10])

Worried by information 3(1.5-4 [0-8])

2(1-3 [0-8])

Women recruited in labour felt that the card should bemade available either in the antenatal clinic (13/20) oron arrival in the labour ward (9/20). Women recruitedantenatally however all thought that the best time toreceive the card was in the antenatal clinic (20/20). Ofthe comments received, eight women thought that thebest role of the information card was as an adjunct todiscussion with an anaesthetist. One mother suggestedthat the card should be in languages other than English.

Conclusions: The epidural information card wasgenerally well received by women. It would be prudentto offer the information sheet in both the antenatalclinic and the labour ward. We are exploring theoptions of translating the information sheet into otherlanguages.

Reference1. White LA, Gorton P, Wee MYK, Mandal N. Written information

about epidural analgesia for women in labour: Did it improveknowledge? International Journal of Obstetric Anesthesia 2003; 12:93-97.

P19 Potential for parenteral drug errors on thelabour ward

R Hignett,* SM Yentis,* G O’Sullivan,† PN Robinson,‡

MYK. Wee§

Departments of Anaesthesia, *Chelsea & Westminster,†St Thomas’, ‡Northwick Park & §Poole Hospitals, UK

Introduction: Parenteral drug errors are an importantcause of morbidity and mortality.1 Such errors havebeen estimated to occur in 1:133 anaesthetics.2 Theworkload on labour ward may be heavy andunpredictable, making obstetric anaesthesia especiallyprone to drug errors.3 Our aim was to estimate thepotential for parenteral drug errors involvinganaesthetists on the labour ward.

Methods: After ethics approval we conducted a surveyof all drugs prepared by or for the obstetric anaesthetistin four units during a 24-h period. Timing, personnelinvolved and details of the drugs were recorded.Results: Data for 30 procedures (20 caesarean sections[mean 8 ± 0.3 drugs], 9 epidurals [2.9 ± 0.4], 1 other)involving 191 drugs, were recorded (Table); data wereunavailable for another four. There was one actual drugerror and one pre-error (error noticed beforeadministration).

Table. Drugs prepared during a 24-h period (n (%)).Route: Intravenous

EpiduralSpinalSubcutaneous and intramuscular

105 (55)34 (18)29 (15)23 (12)

Time prepared: 08.00 – 16.5917.00 – 23.5900.00 – 07.59

96 (50)57 (30)31 (16)

Prepared by anaesthetist 120 (63)Checked by anaesthetist 185 (97)Checked by second person 87 (45)Labelled: Yes / no*

If yes, label signed126 / 6528 (22)

Empty ampoule retained 72 (38)Drugs mixed 93 (49)

*Reason given as ‘for immediate use’ or ‘sterile’ in 97%

Conclusion: Extrapolation of our data suggests thatalmost 70 000 drugs are prepared by or for the obstetricanaesthetist in just our four hospitals each year, over32 000 of them out of hours. Given the many stages ofpreparing and giving drugs, and the readiness withwhich errors occur in this environment,3 such a largepotential for errors demands wider investigation,perhaps on a national scale.

References1. Audit Commission. A Spoonful of Sugar. Audit Commission,

London, 2001.2. Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The

frequency and nature of drug administration error duringanaesthesia. Anaesth Intensive Care 2001; 29; 494-500.

3. Yentis SM, Randall K. Drug errors in obstetric anaesthesia: anational survey. International Journal of Obstetric Anesthesia2003; 12: 246-249.


P20 The Obstetric Anaesthetists’ Association’s UKregistry of high-risk obstetric anaesthesia –final report

D Arawwawala, DP Dob, SM YentisMagill Department of Anaesthesia, Chelsea &Westminster Hospital, London, UK

Introduction: The UK Registry of high-risk obstetricanaesthesia was started in 1996 in order to pool UKexperience on current obstetric and anaestheticmanagement of cardiorespiratory conditions duringpregnancy. The project was stopped in 2003 and wehere present the final figures and trends in reportingduring its seven years.

Methods: A standard data collection form was sent toall members of the OAA, requesting information on allcases of cardiorespiratory disease presenting tomaternity units in the UK. Information was requestedabout the hospital involved, the underlying medicalcondition, antepartum and postpartum management(actual and planned) as well as eventual outcomes. Therate of submission of reports was also examined.

Results: Since 1996, we received 376 case reports:• complex congenital heart disease 70 (19%)• valvular heart disease 119 (32%);• miscellaneous cardiac conditions 155 (41%)• respiratory disease 32 (9%).

The rate of reports fell over the project’s seven years,with 166 reports received in the first two years of theregistry, and 68 in the last two years.

Conclusion: Through the efforts of OAA members theregistry has provided a large collection of informationfor reference, and we thank them for their contributions.The decline in reporting during the registry’s durationsuggests that such voluntary reporting schemes have afinite lifespan, and supports its termination pendingfurther development and funding.

P21 Patient satisfaction with post caesareansection analgesia

S Garg, R KumarDepartment of Anaesthesia, Queen Mary’s Hospital,Sidcup, Kent, UK

Introduction: Use of opioids in regional anaesthesiafor caesarean section is routine in our institution.Postoperative analgesia is prescribed at the discretion ofthe individual anaesthetists. The Royal College ofAnaesthetists (RCA) guidelines1 propose the followingstandards for post caesarean analgesia: a) >90% shouldhave a worst pain score (WPS) of ≤3/10; b) all womenshould be prescribed NSAIDs unless contraindicated; c)>90% should be satisfied or very satisfied with theirpostoperative pain relief. We wished to audit theprescription and administration of analgesics andcompare the adequacy of and patient satisfaction withpost caesarean pain relief against the RCA guidelines.

Methods: All women delivered by caesarean sectionunder regional anaesthesia over a 4-week period wereaudited. At 24 h they were asked to grade their WPS ona scale of 0 to 10, and to qualify their satisfaction withpain relief (unsatisfied, satisfied or very satisfied) forthe last 24-h period. The drug chart was then reviewedto see what analgesics had been prescribed, whetherregular or prn and if regular drugs were given asprescribed.

Results: 50 women were audited:• 21 (42%) had a WPS of ≤3 24 h postoperatively.• 45 (90%) were either satisfied or very satisfied with

their postoperative analgesia,• although 24 (48%) had a WPS between 4 and 8.• All were prescribed NSAIDs if not contraindicated.• 82% had regular oral analgesic prescribed (NSAID,

paracetamol, paracetamol-codeine or a combination),• but only 50% were given them regularly as ordered;• 18% of women had no regular analgesia prescribed.• 98% (49/50) were given regional opioids.

Conclusion: Maternal satisfaction was high in our audit(90%), possibly due to use of regional opioids, althoughthe WPS scores were higher than the RCA standard.We believe this can be further improved by thedepartmental regular analgesia regime that we havesince introduced (paracetamol 1 g q.d.s. and diclofenac50 mg t.d.s, with oral codeine and intramuscularmorphine for rescue analgesia)2 and self administrationof analgesics (to be implemented in our unit), asprevious work has shown it to be safe and effective.Maternal satisfaction after caesarean section can beinfluenced by several other factors like sleep, mobilityand well-being of the baby.

References1. Lack JA, White LA, Thoms GM, Rollin AM. Raising the standard.

A Compendium of audit recipes for continuous qualityimprovement in anaesthesia. 6:13. The Royal College ofAnaesthetists, 2000.

2. Halpern SH, Walsh V L. Multimodal therapy for post-Cesareandelivery pain. Reg Anesth Pain Med 2001; 26: 298-300.


P22 Intrathecal opioid-induced pruritus: audit ofcurrent departmental practice

C Guha, D Blacoe, F BrydenDepartment of Anaesthesia, Glasgow Royal Infirmary,Glasgow, UK

Introduction: Diamorphine 0.3 mg is routinely addedto 0.5% hyperbaric bupivacaine when performingspinal anaesthesia for emergency or elective caesareansections in our department. It had been noted on routineaudit that a number of women suffered from pruritus.Therefore we decided to audit the incidence ofintrathecal opioid-induced pruritus before theintroduction of a treatment protocol using intramuscularnalbuphine 5 mg.1 The audit loop was completed byassessing the incidence of pruritus following this.

Method: A questionnaire was devised enquiring aboutseverity of pruritus at four-hourly intervals followingspinal anaesthesia for a period of 24 h. A gradedscoring system of one to four was used with “one”representing no itch present and “four” representingsevere pruritus.2 Forty women were assessed before theintroduction of the protocol and 40 afterwards.

Results: Of the 80 women surveyed, 66 (82%) hadpruritus at some point in the 24-h period and 15 (19%)had moderate to severe itch requiring treatment. No-onehad a score of three or more at 24 h. Of the first 40women surveyed seven (17.5%) had moderate to severeitch requiring treatment but only two received it. Beforethe introduction of the protocol, oral chlorpheniraminewas given with one woman getting relief of symptoms.Following introduction six women out of eight whoscored three or more for pruritus received treatmentwith five receiving intramuscular nalbuphine. Four ofthese women reported an improvement in prurituswithin four hours of treatment with recurrence only inone. Pruritus improved in the other patient within fourto six hours

Conclusions: This audit has shown that intrathecalopioid-induced pruritus is a common side-effect forwomen after caesarean section. It has also shown that itis necessary for a protocol to be in place in order thatthe women receive appropriate treatment.

Reference1. Alhashemi JA, Crosby ET, Grodecki W, Duffy PJ, Hull KA,

Gallant C. Treatment of intrathecal morphine-induced pruritusfollowing caesarean section. Can J Anaesth 1997; 44: 1060-1065.

2. Charuluxananan S, Kyokong O, Somboonviboon W, LertmaharitS, Ngamprasertwong P, Nimcharoendee K. Nalbuphine versuspropofol for treatment of intrathecal morphine induced pruritusafter cesarean delivery. Anesth Analg 2001; 93: 162-165.

P23 Multidisciplinary approach in themanagement of pregnant women withmultiple sclerosis

M Khare,1 S Francis,2 A May,2 E Howarth1

Departments of Obstetrics1 and Anaesthesia,2

University Hospitals of Leicester, Leicester, UK

Introduction: Multiple sclerosis often occurs in youngadults, affecting women in their reproductive years.With advances in medical care and better therapeuticoptions, more women with multiple sclerosis are goingthrough pregnancy successfully. There have been fewstudies of fetal outcome and pain relief in labour. Wepresent our experience in a tertiary unit that runs aregular maternal medicine and obstetric anaesthesiaantenatal clinic.

Methods: All women with multiple sclerosis were seenin the antenatal clinic and a plan was set out in closeliaison with the neurologist. Disabilities such asimmobility, visual impairment, and bladder and boweldysfunction were assessed early in pregnancy, in orderto deal with them appropriately at delivery and postpartum. Options for labour analgesia were discussedand open access appointments allowed.

Results: There were 31 pregnancies in 22 women withmultiple sclerosis over a 10-year period. The age rangewas 20-39 years. The majority had neurologicalsymptoms and signs at the time of their first antenatalvisit. The interval between time of diagnosis of multiplesclerosis and first pregnancy ranged between one and13 years. All women had term pregnancy except onewho had preterm labour. There were 24 vaginaldeliveries of which six took place with epiduralanalgesia. Six deliveries were by elective caesareansection of which five were conducted under regionalanaesthesia and one under general anaesthesia. Twobabies had syndactyly and two had talipes; there wasone neonatal death. The neurological status of thewomen was unchanged in the immediate post-partumperiod and was not affected by the use of regionalanalgesia/anaesthesia.

Conclusion: Regional anaesthesia/analgesia is beingincreasingly used in patients with multiple sclerosis.Early antenatal counselling allays patients’ anxiety andreduces stress during pregnancy. A multidisciplinaryapproach in these women influences their choice ofpain relief and also helps in successful management.


P24 An audit of epidural blood patch afteraccidental dural puncture at the ListerHospital 1997-2003

C Fortescue, S Gowrie-Mohan, L HariharDepartment of Anaesthesia, Lister Hospital, Stevenage,UK

Introduction: Accidental dural puncture and thesubsequent post dural puncture headache (PDPH) thatoften follows is a rare but potentially seriouscomplication of the epidural and spinal techniques andlumbar puncture. There are several different methods oftreating it once diagnosed, but the most effective is theinjection of autologous blood into the epidural space, orepidural blood patch (EBP). Little is known about theideal volume, end point or improvement obtained whenperforming an EBP, and we sought to examine thesefactors.1 We present our results of 60 EBPs carried outwith these questions in mind.

Method: Patients were identified as part of an ongoingprospective audit of PDPH and its associatedsymptoms. Those with persisting symptoms wereoffered an EBP and the following data noted: hoursafter dural puncture EBP carried out, amount of bloodinjected, endpoint to injection and improvement ofsymptoms over time.

Results: Sixty blood patches were carried out during1997-2003, but five repeat blood patches were excludedfrom the analysis; the mean time after dural puncturewas 70.8 h (range 0-296 h). The mean amount of bloodinjected was 21.9 mL (standard error of mean 0.68),and the endpoint was backache in 41, shoulder ache inone, head pressure in two and not clinically evident in11 patients. The improvement in headache andassociated symptoms is shown in the table (n=55).

Time after EBPImprove-ment 0 h 2 h 24 h 48 h 72 h 1 wk0-59% 1 1 1 1 2 160-79% 7 2 0 1 2 1

80-99% 30 12 9 2 0 0100% 17 30 45 51 51 53

Most patients obtained full relief of headache andassociated symptoms from undergoing EBP but onepatient’s tinnitus has not improved, even after twoyears. No adverse effects were reported from any EBPprocedure.

Conclusion: From our series, EBP is effective in 91%patients after a single procedure and the remaining 9%of patients needed a second EBP. This may be due tothe relatively large volume used to obtain a clear endpoint, but a larger study would be needed to ascertainthis.

Reference1. Taivainen T, Pitkanen M, Tuominen M, Rosenberg PH. Efficacy

of epidural blood patch for postdural puncture headache. ActaAnaesthesiol Scand. 1993; 37: 702-705.

P25 Diagnosis and treatment of intrapartumPDPH using a normal saline bolus

A Wendling, MA FroelichUniversity of Florida, Department of Anesthesiology,Gainesville, Fla, USA

Introduction: The incidence of postdural punctureheadache (PDPH) ranges between 76-85%.1 Symptomsmay start up to 72 h after dural puncture. Severalmeasures to treat or prevent post-partum PDPH,including prophylactic administration of saline, havebeen described. Early intrapartum headache is thoughtto be a sign of pneumocephalus, which mandates atherapeutic approach different from that indicated forPDPH. This report describes a case in which injectionof normal saline via a large bore (20-gauge) intrathecalcatheter intrapartum served as a diagnostic maneuverand therapeutic measure for PDPH.

Case report: A 28-year-old parturient requestedepidural analgesia during labor. An inadvertent duralpuncture was made with an 18-gauge Tuohy needle onthe third pass. A 20-gauge catheter was threaded intothe intrathecal space and she was started on anintrathecal infusion of 0.2% ropivacaine with fentanyl2 µg/mL at a basal rate of 3 mL/h. The patient noted amild headache within one hour of the dural puncture.Nine hours later, her headache increased in severity to aVAS score of 8/10. At that time she was given a10-mL bolus of preservative free normal saline via theintrathecal catheter. The patient’s headache improvedimmediately. She continued to labor with continuousintrathecal analgesia. She went on to have aspontaneous vaginal delivery. Unfortunately, herheadache recurred on post-partum day one and sherequired an epidural blood patch that was successful.

Discussion: PDPH seems to be related to the loss ofCSF. Several methods of reducing the loss of CSF haveshown a reduction in the incidence of PDPH.1,2

However, there are no reports in the literature of anintrathecal saline bolus to diagnose and treatintrapartum PDPH. In our case, the patient sufferedsymptoms immediately after the inadvertent duralpuncture with an 18-gauge Tuohy needle. We usedinjection of 10 mL of normal saline both to elucidatethe etiology of our patient’s peripartum headache and toprovide significant immediate albeit temporary relief ofthe headache. This case suggests that the injection of 10mL of normal saline into the intrathecal space mayprovide both diagnostic information and at leasttemporary relief of early onset PDPH.

References1. Lybecker H, Djernes M, Schmidt JF. Postdural puncture headache

(PDPH): Onset, duration, severity, and associated symptoms: Ananalysis of 75 consecutive patients with PDPH. Acta AnaesthesiolScand 1995; 39: 605-612.

2. Charsley MD, Abram SE. The injection of intrathecal normalsaline reduces the severity of postdural puncture headache. RegAnesth Pain Med 2001; 26: 301-305.


P26 Low dose sequential CSE for women withsevere cardiac disease undergoing caesareansection

EL Hamlyn, CA Douglass, GM Stocks, JA CrowhurstQueen Charlotte’s & Chelsea Hospital, Du CaneRoad, London, UK

Introduction: Cardiac disease is now the joint leadingcause of maternal death in the UK. There is debateregarding the optimal anaesthetic technique forcaesarean section in these patients. We describe thesuccessful use of a low dose, sequential, combinedspinal-epidural (CSE) technique, in four patients with avariety of cardiac diseases, who presented to our unit.

Methods and Results: All women had significantcardiac disease (see table). Pre-operative invasivearterial and central venous pressure monitoring wasestablished. After intrathecal injection, all were placedin full left lateral position to minimise the effects ofaortocaval compression. A deliberately low intrathecaldose of hyperbaric bupivacaine was used andanaesthesia subsequently extended using the epiduralcatheter. No prophylactic vasopressor agents wereused. All remained cardiovascularly stable throughout,except the third patient who developed transienthypotension with associated ST depression. This wastreated with 50-100-µg i.v. boluses of phenylephrine.Oxytocics were avoided where possible, or given byslow i.v. infusion. All delivered healthy babies andwere monitored in the intensive care unitpostoperatively.

2oPH HOCM AS/LAD MSInvestiga-tions

Av. PAP46 mmHg

Dilatedatria

Valve area0.7 cm2

Valve area0.9 cm2

NYHA III III III IIParity 0+1 0+0 1+0 1+0Gestation 32/40 29/40 38/40 34/40Spinal bup. 4 mg 5 mg 5 mg 5 mg+fentanyl 25 µg 25 µg 25 µg 20 µgEpidural0.5% bup

10 mL +fentanyl150 µg

10 mL 3.5 mL +N. saline

5mL

6 mL+N. saline

5mLBlock (cold) T4 T4 T2 T4Systolic BP 110-120 90-135 105-150 125-140CVP (cm) 15-20 16-23 18-26 6-9Blood loss 300 300 500 650Oxytocin 10 units/6 h 2 units

2oPH = secondary pulmonary hypertension and restrictivebiventricular failure; HOCM=hypertrophic obstructivecardiomyopathy; AS/LAD=Aortic stenosis and stenosis of leftanterior descending coronary artery; MS=Mitral stenosis;PAP=pulmonary artery pressure; NYHA=New York HeartAssociation severity.

Conclusion: The versatility of the low dose, sequentialCSE allows its use in a variety of cardiac conditions,combining good anaesthesia with cardiovascularstability. Although each case is considered on itsindividual merit, when regional anaesthesia is indicated,this is now our preferred technique.

P27 The reliability of pulse oximetry in thepresence of painted fingernails

C Guha, KN Litchfield,* M McNeil*University Department of Anaesthesia and Departmentof Anaesthesia, Glasgow Royal Infirmary, Glasgow, UK

Introduction: In the case of an emergency or category1 caesarean section the baby and/or mother are indistress. It has therefore been suggested that the babyshould be delivered within 30 minutes. There are manyfactors that could potentially delay the urgent caesareansection. Traditionally patients have all nail polishremoved from their fingers and toenails when comingto theatre. It is suggested that skin pigments and nailpolish might render pulse oximetry inaccurate.1,2 Pulseoximetry is an integral part of monitoring foranaesthesia especially when general anaesthesia mightbe required. We sought to ascertain if our pulseoximeter was accurate when subjected to painted nails.

Method: We recruited five healthy females and appliednine different nail polishes (two coats) to nine fingers.One nail served as a control. Nail polish colours(various brands) ranged from light shades to opaquewhites and deep reds: lilac, icy mint, pink, flesh, palewhite, vixen red, deep purple, brown, electric pink. Thepulse oximeter (Datex-Ohmeda Cardiocap/5) wasattached to the finger and an initial SpO2 reading, asteady state reading (after 15 s) and pulse rate werenoted. Data were analysed with SPSS using a one-wayANOVA test.

Results: There were no instances of the pulse oximeternoting interference or artefact. When compared to thecontrol finger no reading was significantly different,either initially or at steady state reading.

Conclusion: Using a Datex-Ohmeda Cardiocap/5 pulseoximeter we found no inaccurate readings or artefactswith a range of light to opaque/dark nail polishes. Intimes of extreme urgency it would be safe to leave thepatient’s nail polish on and thereby avoid extra timedelays.References1. Moyle JTB, Davey A, Ward C. Physiological monitoring:

principles and non-invasive monitoring. In: Ward’s AnaestheticEquipment. London: Saunders, 1998: 274.

2. Tidmarsh M, Lin E S. Clinical measurement. In: Pinnock C, LinT, Smith T et al (eds). Fundamentals of Anaesthesia. London:Greenwich Medical Media, 2000: 822.

3. James D. Caesarean section for fetal distress. British MedicalJournal 2001; 322: 1316 – 1317.


P28 Influence of different labour methods onnitric oxide and malondealdehyde levels

L Pirbudak, M Çekmen,* Ö Balat,§ N Tahtacı, FAksoy,§ MG Ugur,§ S Celiköz†

§Department of Anaesthesiology, Obstetrics andGynaecology, †Biostatistics, University of Gaziantep;*Department of Clinical Biochemistry, University ofKocaeli, Kocaeli, Turkey

Objective: In the current study, we assessed theinfluence of three different labour methods on maternaland neonatal oxidant stress. For this purpose, bloodlevels of nitric oxide (NO) and malondealdehyde(MDA) were measured in mothers and neonates, andthe data analysed to predict the method of choice forlabour from oxidative stress point of view.

Methods: 90 women (ASA I-II) were divided into threegroups. Group V comprised mothers with vaginaldelivery and their neonates. Group G included motherswho had caeserean section under general anaesthesiaand their neonates. Group S included mothers who hadcaesarean section with spinal block and their neonates.Blood samples (5 mL) were obtained from the motherbefore and after delivery and from the umbilical artery,for measurement of MDA and NO levels.

Results: The demographic profiles of the groups weresimilar. Postnatal NO levels were found to be increasedsignificantly in both group V and G compared with theprenatal levels (P <0.05). The most significant increasewas observed in group G. Neonatal NO values werehighest in group G and lowest in group V. Maternal andneonatal MDA levels did not differ significantly eitherwithin or between the groups (Table).

Table. NO and MDA values (mean ± SD) before andafter vaginal delivery in maternal venous and umbilicalartery blood.

Group V(n = 30)

Group G(n = 30)

Group S(n = 30)

P (betweengroups)

Maternal before deliveryNOMDA

27.6 ± 4.92.5 ± 0.3

30.5 ± 6.62.6 ± 0.6

29.6 ± 7.32.5 ± 0.5

Maternal after deliveryNOMDA

33.7 ± 8.82.4 ± 0.4

38 ± 62.4 ±

30.6 ± 5.22.3 ± 0.3

0.001 (G-S)

NeonatalNOMDA

25.8 ± 5.92.3 ± 0.3

39 ± 8.162.4 ± 0.6

31 ± 5.92.2 ± 0.4

*

P (withingroup)

0.016(NO)

0.004(NO)

0.049(NO)

*NO between groups: P=0.006 (G-S); P<0.001 (V-G)

Conclusion: In contrast to other oxygen radicals, NOhas important physiological functions. In the group thathad caesarean section under spinal block, no significantelevation was observed in NO levels. Spinal anaesthesiainduces the least oxidant stress, and can be consideredto be the method of choice in caesarean section.

P29 Patient-controlled epidural analgesia orsystemic analgesia alone for pain therapyafter caesarean section?

L Gurlit, M Moellmann, S GurlitDepartment of Anaesthesia & Intensive Care,Muenster, Germany

Introduction: Patient-controlled analgesia (PCA)techniques are popular for post-caesarean section pain.There is much doubt whether caesarean needs such amultimodal approach. This study aims to assesswhether systemic or PCA-epidural (PCEA) analgesiaproduces better pain relief, fewer side effects and bettermaternal satisfaction. The study started after surgeryand finished at the end of the first postoperative day.

Method: After ethics approval, 50 patients scheduledfor caesarean were randomised in two groups. Group 1were given spinal anaesthesia using 0.5% hyperbaricbupivacaine 2.5 mL, and for postoperative analgesia, acontinuous i.v. infusion of novaminsulfone (4 g/24 h),plus i.m. opioids on request (piritramid 15 mg), startedimmediately after surgery. Those in group 2 were givencombined spinal-epidural anaesthesia with 0.5%hyperbaric bupivacaine 2.5 mL and the epiduralcatheter was connected to a PCA pump delivering amixture of bupivacaine 2 mg/mL and sufentanil1 µg/mL (background 2.5 mL/h). A 2-mL bolus with alockout period of 20 min could be obtained. Pain scores(visual analogue scale: VAS) at rest and whencoughing, degree of motor blockade (Bromage scale)and side-effects were assessed 15 min, 4 h, 8 h, 22 hand 32 h postoperatively and volume of localanaesthetic or i.m. opioids consumed was recorded.Maternal satisfaction was measured retrospectively. Forstatistical analysis, Wilcoxon two-sample-test and χ2

test were used.

Results: No difference in demographics was noted.VAS pain scores both at rest and when coughing weresignificantly lower in the PCEA group, moreparticularly on the day of surgery. Throughout the studyperiod, the number of patients with motor blockade wassignificantly higher in the PCEA group; these patientsrequired significantly higher nurse interventions formobilisation, although for analgesic requirements,significantly fewer nurse interventions were neededbecause of the PCEA. Nausea and vomiting were notsignificantly more often recorded in the PCEA group.Maternal satisfaction was excellent in 76% of group 1and in 88% of group 2.

Conclusion: PCEA induced better pain relief, butcaused difficulties in postoperative mobilisationbecause of motor blockade. Since both techniquesresulted in high maternal satisfaction rates, the need forepidural analgesia for post-caesarean pain requiresfurther investigation.


P30 Anaesthetic management for caesarean sectionin a parturient with rigid spine syndrome

R Kumar, D Lee, S Sharafudeen, MP WaterstoneQueen Mary’s Hospital, Sidcup, Kent, UK.

Introduction: Rigid spine syndrome (RSS), firstdescribed by Dubowitz in 1965,1 is a rare childhood-onset muscular disorder, characterised by markedlimitation of flexion of the cervical and dorso-lumbarspine, scoliosis, joint contractures and diffuse muscularweakness. Restrictive ventilatory dysfunction iscommon. Anaesthetic concerns are possible difficultintubation, poor respiratory function, cardiacinvolvement, malignant hyperthermia, problems withmuscle relaxants such as hyperkalaemia followingsuxamethonium and prolonged weakness after non-depolarising agents and technical difficulties withregional anaesthesia. We believe this is the first reportof the successful use of a combined spinal-epidural(CSE) for caesarean section in a woman with RSS.

Case report: A 23-year-old primip (wt 39 kg, ht149 cm), required elective caesarean section at 33/40gestation for worsening respiratory symptoms. She hadsevere kyphoscoliosis, restrictive ventilatory defect andsleep-related hypoventilation requiring regularnocturnal nasal ventilation for the previous 4 years.FEV1/FVC was 1.00/1.26 and the vital capacity was43% of predicted. ECG and echocardiogram werenormal. Airway assessment revealed a Mallampatigrade I view. A preoperative arterial blood gas on airwas normal. A 500-mL crystalloid preload was givenand a CSE inserted easily at L3/4. A 1.8-mL intrathecalinjection of 0.5% hyperbaric bupivacaine withdiamorphine 200 µg achieved a bilateral sensory blockto T6. Epidural top-ups of 0.25% bupivacaine (10 mLin total) were needed for intra-operative discomfort,which extended the block height to T3. Persistentdiscomfort in the left T11-12 segment was relieved byanother 5-mL top-up of 0.5% bupivacaine. She did notrequire any vasopressors or respiratory supportthroughout the operation. A healthy female baby wasdelivered. She received high dependency care whereshe used her own nasal ventilation machine overnightas normal, without any other problems.

Conclusion: Regional anaesthesia was our preferredoption as it avoided all the risks of general anaesthesiaoutlined above. An epidural posed the risk of a patchyblock due to her spinal deformity. CSE enabled us touse a smaller intrathecal dose of local anaesthetic withthe option of topping up the epidural if needed, thusavoiding cardiovascular or respiratory compromise. Ifgeneral anaesthesia had been needed due to CSE failureor an emergency, a modified rapid sequence inductionusing propofol and remifentanil and total intravenousanaesthesia using the two drugs was planned.Reference1. Dubowitz V. Pseudo-muscular dystrophy. In:Research in musculardystrophy.

Proceedings of the Third Symposium, Research Committee of the MuscularDystrophyGroup ofGreat Britain. London:Pitman Medical, 1965:57-73.

P31 Ropivacaine: clinical course of twoparturients who received 30 mg intrathecally

S Steen, M Mok, C WuDepartment of Anesthesiology, Taipei MedicalUniversity Hospital, Taipei

Introduction: Ropivacaine has been recommended forlabor pain management at an initial dose of 20-40 mg,with the proviso that “[The] rapid injection of a largevolume … should be avoided and fractional(incremental) doses should always be used.”1

Case histories: The first patient was a 32-year-oldhealthy primigravid female of 165 cm in height and70.5 kg in weight at 38 weeks’ gestation in active laborwho requested labor analgesia. Vital signs were bloodpressure 134/78, heart rate 85 beats/min, respiratoryrate 26/min, SpO2 98%. After preloading with 1000 mLof normal saline, the patient was placed in the rightlateral position and an 18-gauge epidural needle wasplaced at L2/3 at the first attempt with loss of resistanceby the midline approach. There was no flow of CSFfrom the needle, so the epidural catheter was inserted 5cm into the epidural space. Because of severe laborpain, a 10-mL loading dose of 0.3% ropivacaine wasgiven over 10 s without the use of a test dose. Thisproduced sensory block to C7/T1, with motor block andhypotension requiring ephedrine 16 mg. Laboranalgesia was maintained using the intrathecal catheter.The rest of the labor was uneventful with delivery of ahealthy baby (Apgar and 10) in 5 h.The second patient, a 28-year-old term parturient of168 cm and 62 kg, received a similar 30-mg intrathecalinjection of ropivacaine intended for epidural laboranalgesia. With rapid elevation of the head to Fowler’sposition, sensory block was stabilized at T2 withoutsignificant hypotension, hence no vasopressor wasneeded. This patient had full recovery of motor functionof both legs in 2 h 15 min and delivered a healthy baby3 h after the ropivacaine injection without needingfurther analgesia.

Discussion: These two cases experienced inadvertentintrathecal administration of 30 mg of ropivacaine,which is certainly a large dose. This dose ofropivacaine would be equivalent to 20 mg ofbupivacaine. Based on past experience, 20 mg ofbupivacaine given intrathecally would results in “total”spinal anesthesia with profound hypotension, which wedid not see with ropivacaine. The motor sparing effectof ropivacaine was quite apparent, which is a verydesirable safety feature. Ropivacaine also appears toproduce slower and less profound sympathetic block.This further supports our preference for ropivacaine asthe agent of choice for labor analgesia.

Reference1. Thomson PDR, Montvale, NJ. Physicians’ Desk Reference.

2003; 57: 612-617.


P32 Assessing regional anaesthesia beforecaesarean section: a survey of anaesthetists inAnglia, UK

S Brown, H Prinzhausen, JA PickettAddenbrooke’s Hospital, Cambridge, UK

Introduction: A survey of members of the ObstetricAnaesthetists’ Association was conducted in 1997, toascertain how this group assessed the adequacy ofregional block before caesarean section.1 Temperaturesensation was found to be the most commonly testedsensory modality (64%) with touch sensation assessedby only 7%. An editorial by Russell in 20012 impliedthat both cold and pin prick sensation were unreliableand he recommended that an adequate block to touch bedemonstrated preoperatively (loss of touch sensation toT5). We surveyed anaesthetists providing cover todelivery units in the Anglian region to establish how theadequacy of regional block is currently assessed forcaesarean section.

Method: A questionnaire, similar to that used in 1997,was sent to all consultant obstetric anaesthetists and allanaesthetic specialist registrars in the Anglian region.

Results: 85 questionnaires (75%) were returned. In anuncomplicated parturient for caesarean section, 85% ofthe surveyed anaesthetists would prefer to use spinalanaesthesia, 14% combined spinal epidural (CSE)anaesthesia and 1% either spinal or CSE anaesthesia.The preferred choice of stimulus to assess the adequacyof regional blockade is shown in the figure:

Overall, therefore, cold sensation is used as part of theassessment by 89%, sharp pin-prick by 21% and lighttouch by 26%. The upper level of the block is notalways checked by 3.5% of the anaesthetists in trainingand the lower level of the block is never checked by15.8% of the same group.

Discussion: Within the Anglian region temperaturesensation remains the most popular method of assessingregional block before caesarean section. However,compared to the earlier 1997 survey a larger proportionof our anaesthetists (26%) are using touch sensation.

References1. Bourne TM, de Melo AE, Bastianpillai BA, May AE. A survey

of how British obstetric anaesthetists test regional anaesthesiabefore caesarean section. Anaesthesia 1997; 52: 896-913.

2. Russell IF. Assessing the block for caesarean section.International Journal of Obstetric Anesthesia 2001; 10: 83-85.

P33 The incidence of spinal anaesthesia forcaesarean section in Sierra Leone

A Jalloh, A Kargbo, I Bangura, E Vreede*Nurse Anaesthetist & *formerly Ministry of Health andSanitation, and United Nations Population Fund,Sierra Leone

Introduction: In Sierra Leone, the country with thehighest maternal mortality in the world (2000/100 000),a woman has a 1 in 7 lifetime chance of dying of apregnancy-related complication. Many caesareansections are performed under ketamine withoutintubation. General anaesthesia for caesarean section isa cause of direct maternal death and spinal anaesthesiais associated with lower maternal mortality.1 Therecommendations of the confidential enquiries in SouthAfrica and the UK led to an initiative at PrincessChristian Maternity Hospital to start performingcaesarean sections under spinal anaesthesia.2,3 Thisretrospective audit describes the result of this initiative.

Method: Using the operating theatre register, the typeof anaesthesia was recorded for all caesarean sectionsfor the period October 2000 to June 2002. It wasimpossible to differentiate between elective andemergency sections.

Results: 613 caesarean sections were performed. In thethree months before the initiative none were performedunder spinal anaesthesia, but the percentage roseprogressively thereafter to reach 74.8% (Fig).

Conclusion: This audit demonstrates that the initiativewas successful. It also demonstrates that it is possible toundertake audit in the poor and difficult conditionsexisting in Sierra Leone. The newly qualified NurseAnaesthetists have been posted to District Hospitals andit is expected that they will further promote the use ofspinal anaesthesia in obstetrics. This will hopefully leadto a decrease in maternal mortality from caesareansection.

References1. Fenton P, Whitty C, Reynolds F. Caesarean section in Malawi: a

prospective study of early maternal and perinatal mortality. BMJ2003; 327: 587-590.

2. Saving mothers. Report on the Confidential Enquiries intoMaternal Deaths in South Africa. Department of Health, 1998.

3. Why mothers die 1997 – 1999. The Confidential Enquiries intoMaternal Deaths in the United Kingdom 2001.

57.6

7.11.2

9.416.5

1.27.1

0

20

40

60

80

Cold Pin-prick Touch Cold+Pin-prick

Cold+Touch

Touch+Pin-prick

Othermixtures

Stimuli usedtotest regional blockade

Perc

enta

geus

e

0% 2.7%

21.8%

37.3%

62.6%70.5%

74.8%

Oct-Dec2000

Jan-Mar2001

Apr-Jun2001

Jul-Sep2001

Oct-Dec2001

Jan-Mar2002

Apr-Jun2002


P34 The case fatality rate of eclampsia during theintroduction of magnesium in Sierra Leone

E VreedeFormerly Ministry of Health and Sanitation, and UnitedNations Population Fund, Sierra Leone

Introduction: In Sierra Leone, the country with thehighest maternal mortality in the world (2000/100 000),a woman has a 1 in 7 lifetime chance of dying of apregnancy-related complication.1 In Princess ChristianMaternity Hospital (PCMH), the main referral hospital,eclamptic patients were lying unconscious on adiazepam drip, with compromised airways and withoutmonitoring. Many women died, but no figures wereavailable. This audit was carried out concurrent withthe introduction of magnesium sulphate in order todemonstrate the case fatality rate of eclampsia. It wasalso used to overcome resistance to change and toinitiate quality control.

Method: From August 2001 until September 2002 allwomen admitted to PCMH with convulsions after the20th week of gestation were included. No differentiationcould be made between eclamptic convulsions andthose from other pathologies. The drugs used fortreatment and mortality were recorded. Case fatalityrate was calculated as the number of deaths divided bythe number of women with eclampsia.

Results: 130 women were included. A hospital strikeduring February and March 2002 ceased all activity inthe hospital. Coincidentally this divided the study intwo distinct periods, a period when magnesium wasbeing introduced and one when magnesium was almostuniquely used. During the first quarter preceding thestrike six women died out of 32 (18.8%) and in the finalquarter of the study one out of 40 women died (2.5%)(χ2, P <0.05).

Conclusion: After the introduction of magnesiumsulphate the case fatality rate of eclampsia hassignificantly decreased. Audit is a valuable clinical andteaching tool used here to demonstrate to all hospitalstaff the results of a change in practice in a developingcountry resulting in better care.

References1. AbouZahr C, Wardlaw T. Maternal Mortality in 2000: estimates

developed by WHO, UNICEF and UNFPA. www.unfpa.org

P35 Improving maternal resuscitation throughsimulated peri-arrest scenarios

L Monnery, M Kulkhani, D Halliwell, A McCormickPoole Hospital, Longfleet Road, Poole, Dorset, UK

Aim: To study the effects of simulated peri-arrestscenarios in obstetric patients in terms of performanceand confidence in the resuscitation procedure.

Method: Written consent was obtained from all staff.Five standardised scenarios formed the basis of thedrills; ante-partum haemorrhage (APH), post-partumhaemorrhage (PPH), eclampsia, amniotic fluid embolus(AFE) and total spinal. Time of day, location andparticipants varied between drills. One midwife, givendetails of the ‘patient,’ initiated the drill by soundingthe emergency bell. Times for a number of pre-determined interventions were noted. A debriefingserved to identify any problems encountered. At thecompletion of the AFE drills the participants wereasked to complete a confidence questionnaire.

Results: 13 drills were completed over a 24-monthperiod. Immediate help was available within 49 s andthe cardiac arrest call made within 160 s. Alarm bellswere sometimes inaudible and the volume wasincreased. The basic life support measures of turning toleft lateral, administrating high-flow oxygen, bag tomask ventilation and cardiac compressions were allimplemented within 263 s. Some delay in institutingbag to mask ventilation was due to masks not beingimmediately available and Laerdal face-masks are nowfixed to the wall above each bed. Within 10 min 40 s,where appropriate, the defibrillator had been connected,the trachea intubated and adrenaline given. Delivery ofthe baby was initiated within 9 min in scenarios wheredelivery was appropriate. A reluctance to connect thedefibrillator was observed, evidently due to a lack offamiliarity with the contents of the resuscitation trolley,lack of confidence in rhythm recognition and in abilityto defibrillate. Tutorials were arranged and laminatedcards printed with the algorithms were attached to theresuscitation trolley. A basic surgery set is nowavailable on the resuscitation trolley. Confidence in theteam appeared to improve with a clearly identifiableteam leader. During the study period there have beenthree real-life peri-arrest scenarios; an eclamptic fit, anantenatal haemorrhage and a maternal death fromamniotic fluid embolism.

Discussion: Maternal collapse is rare. Collapse of theparturient poses a unique set of problems. Enactingrealistic scenarios has enabled us to identify easilyrectifiable problems and has given staff confidence inprocedures they would otherwise rarely encounter.

Conclusion: Resuscitation drills are worthwhile interms of improving team-work and confidence andfamiliarising staff with equipment and algorithms. Thevalue in terms of reducing morbidity and mortality isimpossible to determine.

18.8%

8.3%

5.6%

2.5%

Aug-Oct 01 Nov 01-Jan 02 Apr-Jun 02 Jul-Sep 02

Case fatality rate


P36 A prospective observational study of the useof the Proseal laryngeal mask airway forpostpartum tubal ligation

RA Dyer, NR Evans, JJ Skowno, PJ Bennett, MF JamesDepartment of Anaesthesia, University of Cape Town,Groote Schuur Hospital, Observatory, Cape Town,South Africa

Introduction: Though controversial, the risk ofpulmonary aspiration during general anaesthesia in theimmediate post-partum period appears low. Theefficacy and safety of the Proseal laryngeal maskairway (PLMA) was studied prospectively in a group ofpatients undergoing post-partum tubal ligation.

Method: The PLMA was employed for airwaymanagement in 90 fasted patients undergoing tuballigation via minilaparotomy at least 8 h after normalvaginal delivery (mean 36.5, range 8-96 h). Gastricvolume and pH were also measured, using aspirationthrough a gastric tube.

Results: PLMA insertion was successful in all patients,requiring one attempt in 75 patients (83%). The medianleak pressure was 35 (23-40) cmH2O. Twenty twopatients (25%) had a leak pressure of 40 cmH2O orgreater. Gastric tube placement was successful in allpatients, described as easy in 78 (87%), and difficult in12 (13%). The mean initial volume of gastric aspiratewas 10.7 (0-64) mL and the final volume was 15.6 (0-71) mL. The mean pH of the gastric aspirate was 2.6(1.2-6.6). There were no incidents of suspected fluidregurgitation or aspiration. Ten patients (11.1%)complained of a sore throat in the recovery room, nineof which were described as mild. All patients reportedbeing satisfied with their anaesthesia.

Conclusion: The PLMA is effective and probably safefor the provision of an airway for general anaesthesia infasted patients undergoing tubal ligation from eighthours after normal vaginal delivery.

References1. Evans NR. The Proseal laryngeal mask airway: the results of a

descriptive trial with experience of 300 cases. Br J Anaesth2002; 88: 534-539.

P37 Four-grades score to predict the difficulty ofepidural block

M KarrazDept of Anaesthesia, Verdun hospital, Verdun, France

Background and goals: Landmarks on a patient’s backare the best predictor of the difficulty of neuraxial block(DNB).1 We devised a score predicting this difficulty;2

this score contained four grades: grade I: the spinousprocesses (SP) are visible; grade II: the SP are not seenbut easily palpated; grade III: the SP are not seen andnot palpated but the interval between them is palpatedas a low landmark under the thumb; grade IV: none ofthe above. We designed this preliminary study to assessthe validity of this score as a predictor of DNB.

Material and methods: We chose epidural block asone of the neuraxial blocks, and applied it onparturients. Parturients with preeclampsia/eclampsiawere excluded. We defined the difficulty of performingepidural block in two ways: a) the time needed to reachthe epidural space; b) the need to redirect Tuohy needleor to change the intra-vertebral space. We studied 90consecutive parturients. To define the grades using thisscore we asked the parturient to sit down, bend thehead, neck and shoulders toward the chest as much aspossible to protrude her spinous processes. The gradewas determined immediately before starting theepidural procedure, by vision and palpation whenneeded. P <0.05 was considered to be significant.

Results: The results were divided to two groups: easygroup = grade I + grade II; difficult group = grade III +grade IV. We excluded one patient of grade (I) andanother patient of grade (III) due to their movements.

Table 1: Comparing easy and difficult groups:Easy

Grade I+IIDifficult

Grade III+IVP

n 49 (55.7%) 39 (44.3%)

Time (s) * 7.7 ± 2.6 10.7 ± 4.1 <0.001

Number ofdifficulties †

5 11 0.035

*Time needed to reach the epidural space (mean ± SD)†Number of times needed to redirect the Tuohy needleor to change the intra-vertebral space

Conclusion: This score predicts DNB, it is simple, easyto identify, easy to communicate, reproducible, andcould become a basis by which to unifyanaesthesiologists’ language.

References1. Sprung J, Bourke DL, Grass J, et al. Predicting the difficult

neuraxial block: a prosective study. Anesth Analg 1999; 89: 384-389.

2. Karraz M. Primary score predicting the difficulty of neuraxialblock. Anesth Analg 2002; 94: 476.


P38 The obstetric anaesthetic antenatalassessment clinic: a review of 1000 patients

S Francis, SM Yentis, DP DobMagill Department of Anaesthesia, Chelsea &Westminster Hospital, London, UK

Introduction: Antenatal anaesthetic clinics areincreasingly used but published reports are few.1 Wereport the first 1000 patients reviewed in this hospital’santenatal assessment clinic, established in 1994.

Methods: Data were collected using a standard pro-forma and stored electronically, using a previouslydescribed classification.1 The anaesthetic plan proposedwas compared with that at delivery. Local ResearchEthics Committee approval was obtained beforepublication.

Results: The 1000 women were seen betweenNovember 1994 and March 2003. Reasons for referralare shown in the table.

Table. Reasons for referral in 1000 mothersreviewed antenatally. Values are number (%)

Musculoskeletal 372 (37.2%)Cardiac 193 (19.3%)Haematological 103 (10.3%)Anaesthetic 95 (9.5%)Neurological 78 (7.8%)Respiratory 30 (3.0%)Drug-related 25 (2.5%)Other 104 (10.4%)

In the musculoskeletal group, 150 (40%) had non-specific back pain, of whom 77% had regionalanalgesia or anaesthesia (RA); 59 (16%) had scoliosis(73% had RA), 31 (8%) had disc prolapse (74% hadRA), 27 (7%) had discectomies/spinal fusion (70% hadRA), and 19 (5%) had posterior instrumentation (37%had RA). In the cardiac group, 71 (37%) had valvulardisease (75% had RA) and 65 (34%) had congenitalheart disease (83% had RA). In the haematologicalgroup, 18 (17%) had actual or potential clottingdisorders (16 (89%) of whom were receiving heparin);78% had RA and 11% had PCA. Forty-six (45%) hadidiopathic thrombocytopenic purpura or low platelets(51% had RA). Overall, there were deviations from theoriginal anaesthetic plan in <5% of cases.

Conclusion: This hospital has a particular interest incardiac disease so the cases are skewed towards thisarea. It is impossible to prove that the clinic improvesoutcome since we cannot randomise or compare againsta control group. However, the clinic is much valued bythe anaesthetists, obstetricians, midwives and patients.

Reference1. Rosaeg OP, Yarnell RW, Lindsay MP. The obstetrical

anaesthesia assessment clinic: a review of six years experience.Can J Anaesth 1993; 40: 346-356.

P39 Changes in obstetric anaesthetic practice andthe effect on training anaesthetists in a UKDistrict General Hospital 1984-2003

JS SpriggeDepartment of Anaesthesia, Arrowe Park Hospital,Wirral Merseyside, UK.

Introduction: Anaesthetic training in the UK hasaltered in the last 20 years, from a service basedspecialty with almost unlimited time in training to aprescribed time-limited modular training programme. Asafe service delivered by anaesthetic residents intraining which gave them good clinical experience hasgiven way to a service which can be less satisfactoryclinically, and less satisfactory for training. Thecaseload and experience that the residents receive hasdiminished, and it is now difficult for them to obtainadequate training experience,1 although with theexpansion of numbers of consultants and associatedspecialists, the residents have much better prospects ofpromotion. Concurrently, it is possible that the qualityof service offered to patients has deteriorated.

Method: Obstetric anaesthesia is procedure-based. Theanaesthetic experience and practice for trainees andconsultants were analysed by referring to the maternityepidural and theatre records for the period 1984-2003.The records of number of procedures, and grades ofanaesthetists doing them, and incidence of accidentaldural punctures were recorded and compared.

Results: In 1984, anaesthetic registrars performed 75%of the anaesthetics in the maternity unit. In a four-month period, a registrar would perform an average of20 epidurals for analgesia and 20 obstetric anaesthetics.The accidental dural puncture rate was 0.5%. However,none of the registrars from that year were everpromoted to become consultants in the UK. By 1993,career grade expansion had caused the work-load borneby registrars to fall to 45%. In a four-month period, aregistrar would perform an average of 10 epidurals and12 obstetric anaesthetics, and the accidental duralpuncture rate with epidurals rose to 1%. Seven of the 14registrars were promoted to consultants. From 2000onwards, consultant expansion levelled off, and allspecialist registrars are predicted to becomeconsultants. In 2003 the trainees carried 54% of thework load, and in a four-month period, performed anaverage of six epidurals and five obstetric anaestheticseach. The accidental dural puncture rate was 1.3%.

Conclusion: These results show that today’s specialistregistrar is much less experienced than 20 years ago.Modular training schemes need careful organisation toensure that the training has taken place, and thatcompetence has been acquired.

Reference1. Johnson RV, Lyons GR, Wilson RC, Robinson AP. Training in

obstetric general anaesthesia, a vanishing art. Anaesthesia 2000;55: 712-713.


P40 To eat or not to eat? A survey of UKmaternity unit policies regarding oral intakeduring labour

D Hart, A Shennan, G O’Sullivan*Department of Women’s Health Services & *Department ofAnaesthetics, St Thomas’ Hospital, London, UK

Introduction: In 1991 a survey in England and Walesinvestigated policies regarding eating and drinkingduring labour.1 In the intervening years there have beenmajor initiatives published by the Department of Healthcalling for the review of many aspects of maternity careprovision including maternal choice.2 Since the 1980sthere has been a dramatic decline in maternal mortalityrelated to pulmonary aspiration. This is, in part,attributed to the widespread introduction of regionalanaesthesia, improved training in anaesthetics and theuse of antacid therapies. The aims of this survey are toidentify and scrutinise eating and drinking policies forlabouring women in maternity units throughout theUnited Kingdom in 2003 and compare these with thefindings of 1991.

Methods: Anonymous questionnaires were posted tothe Heads of Midwifery in NHS and private maternityunits (n=322) requesting information on currentprotocols, if any, on oral intake during labour. Datawere collected and analysed using Microsoft Excel2000 software. Results were then compared with thoseof the 1991 survey, using a χ2 test (Stata 8.0 forWindows).

Results: A total of 294/322 maternity units (91%)responded. All hospitals permit oral intake of somedescription. Oral intake policies exist in 191 of 294hospitals surveyed (65%). This has decreased by 12%(χ2 10.2, P <0.0014) since the last national survey of1991. Calorific drinks and/or food intake during labourare permitted by 238/294 units (81%), which representsan increase of 50% (χ2 149.15, P <0.00001) in 12 years.Oral antacid prophylaxis is prescribed routinely in111/294 units (38%) but 20% of these units do notrestrict food and drink in labour.

Conclusion: Since 1991 there has been a major changein policies regarding oral intake, with the majority ofunits now permitting calorific intake during labour. Theuse of regional anaesthesia for operative deliveries hasalso significantly increased during this period. TheConfidential Enquiries into Maternal Deaths show thatmortality from pulmonary aspiration is now negligible.If morbidity and mortality remain low, this wouldsuggest that oral intake during labour is not directlyassociated with significant maternal risk.

References1. Michael S, Reilly CS, Caunt JA. Policies for oral intake during

labour. A survey of maternity units in England and Wales.Anaesthesia 1991; 46: 1071-1073.

2. Dept of Health. Changing Childbirth: Report of the ExpertMaternity Group. London, HMSO 1993.

P41 Management of inadequate epidural analgesiaduring labour by obstetric anaesthetists in theParis region

P Abecassis, FJ Mercier, D BenhamouLA. Beclere hospial, Clamart-France

Introduction: A significant number (8-25%) of womenstill have pain during labour epidural analgesia. Theaim of this study was to evaluate how obstetricanaesthetists manage inadequate labour analgesia.

Methods: Questionnaires were distributed in 2003 tothe lead anaesthetist of each obstetric unit in the Parisregion (Ile de France). We investigated which approachwas chosen in the three following situations:1) restricted spread of sensory block, 2) sensory blocknot dense enough, 3) asymmetrical block. For eachsituation, the anaesthetist was asked to rank threeinterventions among a list of several possibilities. Thequestionnaire was tested by a national panel of expertsin obstetric anaesthesia before being sent.

Results: There were 96 answers (91%). In the case ofrestricted spread of sensory block, administration of atop-up of the previously used solution was the actionmost often chosen (81%), followed by injection of amore concentrated local anaesthetic (LA) solution oraddition of an opioid (30% each). Epidural catheterreplacement was used in 20% of cases (thirdintervention chosen). In the case of a sensory block notdense enough, the first choice of intervention wasadministration of a top-up of the previously usedsolution (42%), followed by injection of a moreconcentrated LA solution or addition of an opioid (30%each). Administration of clonidine was the thirdintervention chosen (8%). In the case of asymmetricalanalgesia, the first approach was turning the parturienton the painful side (32%) or topping-up the catheterwith the same solution (32%). The second action mostoften suggested was to pull out the catheter slightly,whereas replacement of the catheter was left as the lastintervention.

Conclusion: The management of restricted spread ofLA with an additional injection of the previously usedsolution seems to be consensual.1 Conversely, whensensory block is not dense enough, several attitudescoexist. Finally, for each situation proposed, catheterreplacement is generally believed to be the last resort.2

References1. Lyons G, Columb MO, Gorton H. Minimum local analgesic

volume for epidural bupivacaine 0.125% in labour. Br J Anaesth1998; 80 (suppl 1): A 511

2. Beilin Y, Zahn J, Berstein HH, et al. Treatment of incompleteanalgesia after placement of an epidural catheter andadministration of local anesthetic for women in labor.Anesthesiology 1998; 88: 1502-1505.


P42 Epidural ropivacaine 0.1% and sufentanil0.6 µg/mL to allow ambulation during labour

M. KarrazCentre Hospitalier de Verdun, Verdun, France.

Introduction: Ambulatory epidural analgesia forlabour is increasingly popular. We have evaluatedprospectively an novel method of providing it.

Method: After ethics committee approval and writtenconsent, 100 consecutive parturients took part in thisstudy (singleton pregnancy and spontaneous or inducedlabour). The epidural catheter was introduced at thelevel of L2-3 and passed 15 cm in from the skin. Weinjected an initial dose of 10-16 mL (according toheight) of ropivacaine 0.1% and sufentanil 0.6 µg/mL,without a test dose, in the dorsal decubitus position.After 15 min, the arterial pressure was measured inthree positions (lying, sitting, standing). The i.v.infusion was discontinued after 1000 mL of Ringerlactate had been given, while maintaining venousaccess. The Bromage score and modified Bromagescore, and 100-mm visual analogue pain score (VAS)were measured before and 20 min after each epiduraldose. There were three pre-conditions to allowambulation: the ability to stand on either legindividually, blood pressure on standing ≥100 mmHg,VAS ≤30 mm. Analgesia was maintained by 10-mLepidural top-ups of the same solution on demand, in allparturients, in the dorsal position. Ringer Lactate500 mL was given with each top-up. Results arepresented as mean ± standard deviation.

Results: Nine parturients did not ambulate: fivebecause delivery followed within 15 min of epiduralinsertion, two because of transient fetal bradycardia andtwo because of fatigue; 91 parturiants walked 20 minafter the initial injection and top-up: Bromage score 4,modified Bromage 6; VAS 77 ± 17 mm before theepidural and ≤30 mm 20 min after each injection,except in two women who needed 5-mL supplements ofthe same solution to provide analgesia. Parturients weregiven 1-6 doses and the interval between doses was 106± 24 min.

Discussion: The failure of nine parturients to ambulatewas unrelated to the method of analgesia. We achievedanalgesia without motor block (Bromage score = 4) and91 parturients walked; we know of no other such resultsin the literature. The length of catheter that isintroduced into the epidural space, 7-12 cm, is similarto that recommended for medullary neurostimulation.We did not use a test dose, because we did not wish tojeopardise the chance of ambulation by producingmotor block; we would emphasise that each bolus canbe considered a test dose.

Conclusion: This method of providing ambulatoryepidural analgesia can permit parturients to walkwithout help in total safety.

P43 Use of low-molecular-weight heparin from thefirst trimester of pregnancy: a retrospectivestudy of 111 consecutive pregnancies

A-S Ducloy-Bouthors, P Deruelle, M Denervaud,E Hachulla, A-S Valat, F Puech, N Trillot, P-Y Hatron,D SubtilClinique d’Obstétrique. Hôpital Jeanne de Flandre, MédecineInterne, Laboratoire d’hématologie Chru de Lille, France

Introduction: We wished to discover the maternal andfetal tolerance for low-molecular-weight heparin begunin the first trimester of pregnancy. We thereforeconducted an observational study of women whoreceived LMWH during pregnancy, to assess theincidence of adverse events that might be attributed toLMWH in mother and fetus. All patients begantreatment before the fifteenth week of pregnancy.Methods: The medical charts of women treatedbetween 1 January 1997 and 31 May 2001 with LMWHbefore the fifteenth week of pregnancy were reviewed.Results: The study included 97 patients (and 111pregnancies) at very high risk. Seven fetal losses(6.3%) were observed: three early spontaneousabortions, three late spontaneous abortions and onemedically-indicated abortion. Twenty-five (22.5%)bleeding events occurred during pregnancy, seven(6.3%) of which required medical intervention: fivecurettages for first trimester spontaneous abortions, onelate abortion at 21 weeks, and one placental abruptionat 25 weeks. Of nine (8.1%) primary post-partumhaemorrhages involving blood loss ≥500 mL, threeinvolved losses of ≤1000 mL and one requiredembolisation of the uterine arteries. Five patients hadthrombocytopenia, but none was treatment-related.Local cutaneous reactions occurred in 33 patients(29.7%). Six (5.4%) maternal thromboemboliccomplications occurred during pregnancy or postpartum. At birth, two children had non-chromosomalcongenital malformations (pyelectasia, cleft lip andpalate). No fetal or neonatal complication wasattributed to the treatment.Discussion: LMWH does not cross the placenta.1 Itssafety when administered in the second and the thirdtrimesters was studied in 624 pregnant patients,2 whohad complication rates similar to ours: serious maternalhaemorrhage (1.8% vs 1.8%), congenital malformations(2.5% vs 1.8%). Thromboembolic events were morefrequent in our series (1.3% vs 5.4%) but we did notobserve any neonatal haemorrhage (1.4% vs 0%).Conclusion: The use of LMWH for patients requiringanticoagulant treatment from the first trimester appearssafe for mother and fetus.References1. Dimitrakakis C, Papageorgiou P, Papageorgiou I, Antzaklis A,

Sakarelou N, Michalas S. Absence of transplacental passage of thelow molecular weight heparin enoxaparin. Haemostasis 2000; 30:243-248.

2. Lepercq J, Conard J, Borel-Derlon A, et al. Venous thrombo-embolism during pregnancy: a retrospective study of enoxaparinsafety in 624 pregnancies. BJOG 2001; 108: 1134-1140.

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