A patient with hypoparathyroidism, dysmorphic features and mental retardation

There have been various reports in the medical literature concerning children with syndromes of congenital hypoparathyroidism, seizures, dysmorphic features and mental retardation. We describe a patient with hypoparathyroidism, mental retardation, micrognathia, deep-set eyes and pes cavus in a 31-year-old man. This combination of abnormalities in an adult is unique.

Ketorolac and spinal morphine for postcesarean analgesia

This study was designed to compare spinal morphine (SM), ketorolac (K), and a combination of the two drugs with respect to analgesic efficacy and side effects in postcesarean patients. Forty-eight parturients having bupivacaine spinal anesthesia for cesarean delivery randomly received in a double-blind manner either: SM: 0.1 mg or SM: 0.2 mg (but no K); SM: 0.1 mg plus K 60 mg intravenously (i.v.) one hour after spinal injection, and 30 mg i.v. every 6 h for three doses or i.v. K dosed as previously described (but no SM). Analgesia and side effects were evaluated during the first 20 h. Forty-eight women were studied. There were no significant differences in analgesia among the groups, although patients receiving SM: 0.1 mg tended to have less satisfactory intraoperative analgesia. Pruritus was common in all patients receiving SM whereas patients who received K had the lowest overall scores for severity of side effects. No serious complications occurred and all groups expressed similarly high satisfaction at the 24 h visit. We conclude that there is no advantage to combining SM and K, and that K provides satisfactory postcesarean analgesia with few side effects.

Prevention of hypotension after spinal anesthesia for cesarean section: six percent hetastarch versus lactated Ringer's solution

This study was designed to determine whether preoperative administration of 6% hetastarch decreases the incidence and severity of hypotension after spinal anesthesia for cesarean section. Forty nonlaboring ASA class I and II women having nonurgent cesarean sections were randomized to receive either 500 mL of 6% hetastarch plus 1 L lactated Ringer's solution (LR) (n = 20), or 2 L of LR (n = 20) prior to induction of spinal anesthesia. Hypotension occurred in 45% of patients who received hetastarch vs 85% of those who received only LR (P < 0.05), and minimum systolic blood pressure was lower in the LR group than in the hetastarch group (85 +/- 12 vs 93 +/- 12 mm Hg [mean +/- SD]; P < 0.05). In addition, the LR group had a higher maximum heart rate (115 +/- 17 vs 104 +/- 16 bpm), a shorter mean time to hypotension (7 +/- 4 vs 10 +/- 7 min), and required more 5-mg doses of ephedrine for treatment of hypotension (0 vs 2 [median]; P < 0.05) than the hetastarch group. Neonatal outcome, as determined by Apgar scores and cord blood gas analyses, was good and similar in both groups. We conclude that 6% hetastarch plus LR is more effective than LR alone and that its routine use before spinal anesthesia for cesarean section should be considered.

Placental transfer and neonatal effects of epidural sufentanil and fentanyl administered with bupivacaine during labor

BACKGROUND

This randomized double-blind investigation was designed to study the placental transfer and neonatal effects of epidural sufentanil and fentanyl infused with bupivacaine for labor analgesia.

METHODS

Healthy parturient women (n = 36) received epidural bupivacaine alone (group B) or with fentanyl (group B-F) or sufentanil (group B-S). Group B received a 12-ml bolus of 0.25% bupivacaine followed by a 10 ml/h infusion of 0.125% bupivacaine. Groups B-F and B-S received a 12-ml bolus of 0.125% bupivacaine with 75 micrograms fentanyl or 15 micrograms sufentanil, respectively, followed by 10 ml/h of 0.125% bupivacaine with fentanyl 1.5 micrograms/ml or sufentanil 0.25 micrograms/ml. Maternal venous (MV) and umbilical arterial (UA) and umbilical venous (UV) bupivacaine and opioid plasma concentrations were determined. Neonatal assessment included Apgar scores, umbilical cord blood gas analyses, and neurobehavioral testing at delivery and at 2 and 24 h of life using the Neurologic and Adaptive Capacity Score (NACS).

RESULTS

The mean total dose of fentanyl was 136.6 +/- 13.1 micrograms (SEM), and of sufentanil, 23.8 +/- 1.8 micrograms. Although administered in a ratio of 5.7:1, fentanyl and sufentanil MV plasma concentrations were in the ratio of 27:1. UV/MV ratios were 0.37 for fentanyl and 0.81 for sufentanil. Fentanyl was detected in most UA samples, whereas sufentanil was present in only one sample. Neonatal condition was good and generally similar in all groups, with the exception of a lower NACS at 24 h in group B-F.

CONCLUSIONS

Although the degree of placental transfer of sufentanil appeared greater than that of fentanyl, lower MV sufentanil concentrations resulted in less fetal exposure to sufentanil. The lower NACS at 24 h in group B-F may reflect the continued presence of fentanyl in the neonate.

Spinal versus epidural anesthesia for cesarean section: a comparison of time efficiency, costs, charges, and complications

Spinal anesthesia recently has gained popularity for elective cesarean section. Our anesthesia service changed from epidural to spinal anesthesia for elective cesarean section in 1991. To evaluate the significance of this change in terms of time management, costs, charges, and complication rates, we retrospectively reviewed the charts of patients who had received epidural (n = 47) or spinal (n = 47) anesthesia for nonemergent cesarean section. Patients who received epidural anesthesia had significantly longer total operating room (OR) times than those who received spinal anesthesia (101 +/- 20 vs 83 +/- 16 min, [mean +/- SD] P < 0.001); this was caused by longer times spent in the OR until surgical incision (46 +/- 11 vs 29 +/- 6 min, P < 0.001). Length of time spent in the postanesthesia recovery unit was similar in both groups. Supplemental intraoperative intravenous (i.v.) analgesics and anxiolytics were required more often in the epidural group (38%) than in the spinal group (17%) (P < 0.05). Complications were noted in six patients with epidural anesthesia and none with spinal anesthesia (P < 0.05). Average per-patient charges were more for the epidural group than for the spinal group. Although direct cost differences between the groups were negligible, there were more substantial indirect costs differences. We conclude that spinal block may provide better and more cost effective anesthesia for uncomplicated, elective cesarean sections.

Parturient's posture during epidural puncture affects the distance from skin to epidural space

STUDY OBJECTIVE

To assess the factors affecting the distance from skin to epidural space.

DESIGN

Prospective observational study of consecutive cases over a 2-year period.

SETTING

Inpatient obstetric unit in a French university hospital.

PATIENTS

2,123 consecutive term parturients who received epidural anesthesia for cesarean section or epidural analgesia for labor and vaginal delivery.

INTERVENTIONS

At the time of epidural puncture, the interspace used and the patient's posture (sitting or left lateral decubitus) were recorded, and the distance from the skin to the epidural space (DS-ES) was measured to the nearest 0.5 cm using a marked epidural needle.

MEASUREMENTS AND MAIN RESULTS

The relationship between patient factors [height, weight, body mass index (BMI; weight/height2), presence of scoliosis] and technical factors (interspace, patient's posture at puncture) versus DS-ES was investigated using multiple regression analysis. DS-ES correlated positively with the parturient's weight and BMI. In addition, DS-ES was significantly greater when epidural puncture was performed in the lateral position as compared with the sitting position.

CONCLUSION

Both the patient's weight and position during epidural needle placement are important factors influencing DS-ES. A change from the sitting to the lateral position may increase DS-ES, causing catheter dislodgment and consequent inadequate analgesia. Clinical studies relating DS-ES to inadequate analgesia must take these factors into account.

Biosocial factors in early infancy as predictors of competence in adolescents who were born prematurely

In a prospective longitudinal study of a cohort of 105 subjects born prematurely, competence was assessed from infancy through late adolescence. A biosocial model guided the research. Neonatal neurobehavioral organization (a composite of term visual attention, amount of time in active sleep, and 407 EEG pattern) and early social stimulation (the amount of talking the mother addressed to the infant during a home observation when the infant was 1 month old) in conjunction with social class were used to predict competence at key age periods through late adolescence. Intellectual competence, school achievement, social competence, and self perception of cognitive competence were studied. The results indicate that measures taken in the early infancy period were predictive of later competence, particularly intellectual competence, above and beyond social class. Twenty-eight percent of the variance in 18-year IQ scores was explained by the predictor variables. The study highlights the importance of directing efforts to improve the social environment of both the infant and the family.

Intrathecal sufentanil for labor analgesia--sensory changes, side effects, and fetal heart rate changes

This study was designed to evaluate intrathecal (IT) sufentanil for labor analgesia with respect to sensory changes, side effects, and fetal heart rate (FHR) changes. In Phase I of the study, data regarding duration of analgesia and hemodynamic changes were obtained retrospectively from the labor and anesthetic records of 90 patients who had received IT sufentanil, 10 micrograms in 1 mL of saline, during active labor. In Phase II, an additional 18 parturients who received similar treatment were studied prospectively to document sensory, motor, and hemodynamic changes, as well as the incidence of side effects. In Phase I, analgesia occurred rapidly and lasted 124 +/- 68 min (SD); 19% of patients required no further analgesia before delivery. In Phase II, median time to onset of analgesia was 3 min (range 1-6 min) and mean duration of analgesia was 96 +/- 36 min. Decreased sensation to pinprick and cold occurred within 6 min extending from T4 to L4 (upper and lower median levels) in the majority of patients. All subjects requested additional analgesia within approximately 30 min of recession of sensory changes. Motor strength remained normal throughout. Hypotension (systolic blood pressure [BP] < or = 90 mm Hg or > 20% decrease in systolic BP) occurred in 14% and 11% of patients in Phase I and II, respectively. Perineal itching preceded analgesia in 95% of patients and all subjects experienced mild sedation. FHR changes occurred in 15% of cases but were not associated with adverse neonatal outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Nalbuphine is better than naloxone for treatment of side effects after epidural morphine

This study compared naloxone and nalbuphine when administered for treatment of side effects after epidural morphine, 5 mg, given for postcesarean analgesia. Patients requesting treatment for pruritus or nausea randomly received, in a double-blind fashion, up to three intravenous doses of either naloxone 0.2 mg (group 1; n = 20) or nalbuphine 5 mg (group 2; n = 20). The incidence of vomiting, the severity of nausea and pruritus, and the degree of sedation and pain were assessed before and 30 min after each dose. The first dose of nalbuphine decreased the incidence of vomiting (P < 0.005) and the severity of nausea and pruritus (P < 0.01), whereas naloxone caused no significant changes. Sedation scores increased after nalbuphine (P < 0.05) and remained unchanged after naloxone, whereas pain scores increased after naloxone (P < 0.01) and were unchanged after nalbuphine. Eighteen patients in group 1 and 12 in group 2 received a second dose, and 8 and 4 patients, respectively, a third dose. Other than decreased pruritus after the second dose with both drugs, no further changes occurred. We conclude that nalbuphine is superior to naloxone for the treatment of side effects after epidural morphine. However, persistent symptoms may require supplemental therapy, as repeated doses proved less effective than the initial dose.

Emergent applications of cardiopulmonary support: a multiinstitutional experience

The use of emergent portable bypass systems is increasing. Because of limited patient use in any one institution, a combined experience can better determine the applicability of these systems. A total of 187 patients from 17 centers were analyzed. Causes leading to bypass initiation were cardiac arrest (125 patients), cardiogenic shock (44), profound hypothermia (7), pulmonary insufficiency (9), and miscellaneous (2). Weaning from bypass was successful in 30.5% (57 patients). Sixty-four patients (34.2%) were transferred to standard bypass or other modes of circulatory assist. Of the total population, 40 patients (21.4%) were alive greater than 30 days. There were no survivors of unwitnessed arrests. Major diagnostic or therapeutic interventions were carried out on bypass in 74.9% of all patients. In survivors, 77.1% (37/48) had major therapeutic interventions as compared with 50.0% (67/135) of nonsurvivors. Emergency portable bypass systems can successfully resuscitate and support cardiac hemodynamics, although the underlying causes necessitating bypass remain difficult to correct. When corrective intervention can be performed, there is an increased chance of survival. Unwitnessed arrest, prolonged cardiopulmonary resuscitation, and lack of treatment options are relative contraindications. Appropriate patient selection and early application of these systems should lead to improved survival.

Respiratory effects of epidural sufentanil after cesarean section

The ventilatory response to CO2 was measured to evaluate the degree of respiratory depression after epidural sufentanil. After cesarean section performed with bupivacaine epidural anesthesia, 14 patients received either 30 micrograms (n = 7) or 50 micrograms (n = 7) of epidural sufentanil. Respiratory measurements were made before and 15, 45, and 120 min after sufentanil injection. The presence and severity of sedation and other nonrespiratory side effects were evaluated throughout the study. Plasma sufentanil assays were performed on blood samples obtained at frequent intervals during the first 2 h. Although changes in resting ventilation did not occur, both sufentanil doses depressed the ventilatory response to CO2. After sufentanil 30 micrograms, the slope of the CO2 response curve decreased significantly at 45 and 120 min (control value, 2.33 +/- 0.3 L.min-1.mm Hg-1 [mean +/- SEM] vs 1.61 +/- 0.24 and 1.72 +/- 0.15, respectively, P less than 0.05). After sufentanil 50 micrograms, significant decreases occurred at 15 and 45 min (control value, 2.84 +/- 0.71 vs 1.81 +/- 0.48 and 1.48 +/- 0.31 L.min-1.mm Hg-1, respectively). The mean maximal decrease in the slope occurred at 45 min and was more pronounced after 50 micrograms (-42.3% +/- 7.4%) than after 30 micrograms (-27.4% +/- 9.9%). Analgesia was similar in both groups. Side effects, particularly sedation, were more severe with the 50-micrograms dose. We conclude that 30 micrograms of epidural sufentanil is preferable to the higher dose with regard to both respiratory and nonrespiratory side effects. Even with the lower dose, monitoring of ventilation is advisable for a minimum of 2 h.

Fetal heart rate after epidural lidocaine and bupivacaine for elective cesarean section

This prospective double-blind study was designed to determine whether the fetal heart rate (FHR) changes that have been reported after epidural administration of bupivacaine and lidocaine during labor are present when larger doses of these drugs are given during elective cesarean section. Prior to inserting an epidural catheter, FHR and maternal vital signs were monitored during a control period in 60 healthy term parturients. Patients were randomly assigned to receive either 0.5% bupivacaine with 0.1 mEq sodium bicarbonate added to each 20 ml (n = 30) or 2% lidocaine with 1:300,000 epinephrine (n = 30). A 3-ml test dose of the study solution was injected via the catheter and was followed by an additional 17 ml, in increments; additional doses were administered as necessary to obtain surgical anesthesia. FHR and maternal vital signs were monitored for at least 20 min and the characteristics of the anesthetic block noted. At delivery, neonatal status was evaluated, and maternal and cord blood samples were obtained for local anesthetic assays and neonatal blood gases. The groups were similar with respect to maternal characteristics, onset of surgical anesthesia, time to delivery, and uterine incision-delivery interval. Maternal blood pressure decreased from control values in both groups (P less than 0.05), but there was no difference between the groups in either the incidence of hypotension or ephedrine requirements. Analysis of FHR tracings by a perinatologist blinded to the study group revealed no changes after anesthesia and no significant differences between the groups at any time in basal FHR, short- or long-term variability, or the incidence of accelerations or decelerations.(ABSTRACT TRUNCATED AT 250 WORDS)

Neuropsychological functioning in human immunodeficiency virus type 1 seropositive children infected through neonatal blood transfusion

The neuropsychological development of 15 human immunodeficiency virus type 1 (HIV-1) seropositive children infected through neonatal blood transfusion was compared with that of a control group of 33 HIV-1 seronegative children who had also received blood transfusions as neonates. Human immunodeficiency virus type 1 infection was identified on the basis of a callback blood testing. Two thirds of the HIV-1-infected children were asymptomatic at time of enrollment in the study of development. The children were administered two psychological batteries approximately 8 months apart. The results indicated that the two serostatus groups did not differ in overall intelligence, even as long as 8 years after HIV-1 infection. Significant group differences, though slight, were found on school achievement and on tasks that require motor speed, visual scanning, and cognitive flexibility. Continued longitudinal study of this cohort will be important in characterizing the evolution of neuropsychological deficits.

Ventilatory response to carbon dioxide after epidural clonidine injection

The authors studied the effects of epidural clonidine (300 micrograms) on circulation and ventilatory control in seven healthy unpremedicated subjects. After clonidine injection, arterial blood pressure decreased significantly in all subjects (range, 13%-25% for systolic blood pressure and 13%-32% for diastolic blood pressure). Heart rate decreased significantly by 10%-16% between 75 and 105 min after injection. The slope of the ventilatory response to CO2 decreased significantly from 2.06 +/- 0.70 (baseline) to 1.37 +/- 0.68, 1.25 +/- 0.65, and 1.33 +/- 0.67 L.min-1.mm Hg-1 (mean +/- SD, P less than 0.05) at 15, 60, and 120 min. The authors conclude that epidural clonidine induces mild ventilatory and circulatory depression.

Analgesia after cesarean delivery: patient evaluations and costs of five opioid techniques

The study was designed to compare five opioid analgesic regimens administered after cesarean delivery in a routine hospital setting with respect to patients' perceptions of their pain relief and the impact of analgesic technique on recovery and hospital costs. After cesarean delivery, 684 patients received one of the following: epidural morphine, alone (EM,n = 128), or with fentanyl (EM + F,n = 245); subarachnoid morphine (n = 48); intramuscular meperidine (n = 165), or patient-controlled analgesia using meperidine (PCA, n = 98). On the first three postoperative days (Days 1-3; day of operation is Day 1) patients were surveyed regarding their impressions of their analgesia, the incidence of side effects, times to resume normal activities and satisfaction with their technique. Information regarding drug interventions and costs was obtained from anesthetic records and nursing charts. Patients receiving intramuscular and PCA opioids reported significantly more severe pain during the first 16 hours than those receiving intraspinal opioids (p less than 0.05); differences were minimal for the remainder of Day 1. Among the intraspinal groups, analgesia was best overall with EM; specifically, fentanyl did not decrease early postoperative pain. Analgesia with PCA and intramuscular opioids was similar during the first 16 hours; however, PCA patients felt they had less pain thereafter. Side effects were common in all intraspinal groups and were least frequent with PCA (p less than 0.05 versus all intraspinal groups). Times to sit, walk and drink were similar in all patients except those receiving intramuscular opioids after general anesthesia, who experienced a several-hour delay. Other aspects of recovery did not differ among the groups. Satisfaction parallelled pain relief and was better with intraspinal than with systemic opioids. Costs were greatest with PCA, although differences were small (less than 1%) relative to total hospital charges.

Maternally administered esmolol decreases fetal as well as maternal heart rate

Fetal heart rate was monitored during the administration of esmolol 100 micrograms/kg/min to a 36-year-old, 29-week pregnant woman who was undergoing craniotomy for surgical treatment of six cerebral aneurysms. During stable general anesthesia, sodium nitroprusside was administered to induce moderate hypotension; at the same time, esmolol was infused to control maternal tachycardia. Within minutes after starting the esmolol infusion, maternal heart rate decreased from 100 beats/minute to 65 beats/minute, and fetal heart rate decreased from 160 beats/minute to 130 beats/minute. Upon termination of the infusion 3 hours later, both maternal and fetal heart rate returned to preinfusion values. No adverse effects of esmolol infusion were noted in the mother or fetus.

Mothers' use of personal pronouns when talking with toddlers

The verbal interaction of 2-year-old children (N = 46; 16 girls, 30 boys) and their mothers was audiotaped, transcribed, and analyzed for the use of personal pronouns, the total number of utterances, the child's mean length of utterance, and the mother's responsiveness to her child's utterances. Mothers' use of the personal pronoun we was significantly related to their children's performance on the Stanford-Binet at age 5 and the Wechsler Intelligence Scale for Children at age 8. Mothers' use of we in social--vocal interchange, indicating a system for establishing a shared relationship with the child, was closely connected with their verbal responsiveness to their children. The total amount of maternal talking, the number of personal pronouns used by mothers, and their verbal responsiveness to their children were not related to mothers' social class or years of education.

Oxyhemoglobin saturation following cesarean section in patients receiving epidural morphine, PCA, or im meperidine analgesia

The frequency and severity of oxyhemoglobin desaturation was compared in 49 patients receiving epidural morphine, 5 mg (n = 21); patient-controlled analgesia (PCA) using meperidine (n = 20); or intramuscular (im) meperidine (n = 8) for postoperative analgesia following elective cesarean section performed with epidural anesthesia. Oxygen saturation (SpO2) was monitored for 24 h using a pulse oximeter; data were continuously collected and stored every 30 s via an interface connected to a computer. For analysis purposes, SpO2 was divided into five categories: 96-100%, 91-95%, 86-90%, 81-85%, and less than or equal to 80%. Although SpO2 remained above 95% for the majority of the monitored period, patients in all groups experienced periods of desaturation. PCA patients spent the longest cumulative time with SpO2 between 91 and 95%, 231 +/- 49 min (mean +/- SEM), compared with only 112 +/- 30 min and 152 +/- 42 min for the epidural and im groups, respectively (P less than 0.05 vs. epidural group). PCA patients also spent longest with SpO2 at 86-90% (19 +/- 10 min, vs. 6 +/- 3 and 0.5 +/- 0.3 min for the epidural and im groups, respectively), although this difference was not statistically significant. Severe desaturation episodes, defined as SpO2 less than or equal to 85% for more than 30 s, occurred in 71% of patients in the epidural group, 30% in the PCA group, and 63% in the im group (P less than 0.05 PCA vs. epidural and im).(ABSTRACT TRUNCATED AT 250 WORDS)

AIDS-related Kaposi sarcoma: findings on thallium-201 scintigraphy

No simple, noninvasive method is available for evaluating extracutaneous Kaposi sarcoma in AIDS patients or for following the tumor's response to treatment. We report our preliminary experience with thallium-201 scintigraphy in nine AIDS patients with proved Kaposi sarcoma. Eight of the nine had abnormal uptake of the radionuclide in skin, lymph nodes, oral cavity, vagina, and lungs. Only four of the nine had cutaneous Kaposi sarcoma at the time of scanning. All cutaneous and mucosal lesions were thallium avid. Two of the six patients with thallium-avid nodes underwent nodal biopsy. Both biopsies confirmed the diagnosis of Kaposi sarcoma. Cutaneous Kaposi sarcoma developed later in one of these patients, showing the efficacy of thallium scintigraphy for the early detection of extracutaneous lesions. These preliminary results show thallium avidity in Kaposi sarcoma involving the skin and various extracutaneous sites (lymph nodes, lung, mucosa, and vagina). Thallium scintigraphy is a potentially useful procedure for detecting extracutaneous Kaposi sarcoma in AIDS patients.