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Comparison of postoperative analgesic effect of intrathecal clonidine and fentanyl added to bupivacaine in patients undergoing cesarean section: a prospective randomized double-blind study. PAIN RESEARCH AND TREATMENT 2014; 2014:513628. [PMID: 24649361 PMCID: PMC3932201 DOI: 10.1155/2014/513628] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 11/18/2013] [Accepted: 12/03/2013] [Indexed: 11/21/2022]
Abstract
Objectives. To compare the analgesic efficacy of intrathecal clonidine and fentanyl added to bupivacaine after cesarean section. Methods. Ninety patients scheduled for cesarean section under spinal anesthesia were randomly allocated to one of the three following groups to receive bupivacaine 10 mg combined with 75 µg clonidine (group C), bupivacaine 10 mg combined with 0.5 mL fentanyl (group F), and bupivacaine 10 mg combined with 0.5 mL distilled water (group P), intrathecally. The time to first analgesic request, analgesic requirement in the first 24 hours after surgery, sensory and motor blockade onset time, duration of sensory and motor blockade, the incidence of hypotension, ephedrine requirements, bradycardia, and hypoxemia were recorded. Results. The duration of anesthesia in clonidine group (275.10 ± 96.09) was longer compared to the placebo (211.73 ± 74.80) and fentanyl (192.33 ± 30.36) groups. This difference between group C versus F (P = 0.006) and P groups (P < 0.001) was significant. Similarly, the mean time to first analgesic request was also longer in group C (519.44 ± 86.25) than in groups F (277.88 ± 94.25) and P (235.43 ± 22.35 min). This difference between group C versus F (P < 0.001) and P groups (P < 0.001) was significant. Conclusion. Intrathecal clonidine 75 µg with bupivacaine prolonged the time to first analgesic request compared to fentanyl; however, the total analgesic consumption within the first 24 h postoperative was similar in fentanyl and clonidine groups following cesarean section. This trial is registered with ACTRN12611000909921 and ClinicalTrials.gov NCT01425658.
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Park SM, Mangat HS, Berger K, Rosengart AJ. Efficacy spectrum of antishivering medications. Crit Care Med 2012; 40:3070-82. [DOI: 10.1097/ccm.0b013e31825b931e] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Intravenous dexmedetomidine as an adjunct for labor analgesia and cesarean delivery anesthesia in a parturient with a tethered spinal cord. Int J Obstet Anesth 2009; 18:258-61. [PMID: 19188060 DOI: 10.1016/j.ijoa.2008.10.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Revised: 10/29/2008] [Accepted: 10/30/2008] [Indexed: 11/22/2022]
Abstract
For parturients desiring labor analgesia who have contraindications to neuraxial techniques, intravenous opioid-based patient-controlled analgesia (IVPCA) offers a reasonable alternative, although incomplete analgesia and maternal and neonatal respiratory depression can occur. Dexmedetomidine, a highly selective alpha(2) agonist with negligible placental transfer, may be a valuable adjunct to IVPCA by providing additional analgesia without the respiratory depression associated with increasing opioid usage. The successful use of a dexmedetomidine infusion as an adjunct to unsatisfactory fentanyl IVPCA is reported in a 31-year-old parturient with spina bifida occulta and a tethered spinal cord reaching L5-S1. Dexmedetomidine significantly improved the analgesic quality; increased sedation was observed, but the patient was easily rousable to verbal stimuli. No episodes of maternal hypotension or bradycardia, or fetal heart rate irregularities occurred. Cesarean delivery was required for prolonged first stage of labor and presumed chorioamnionitis; it was conducted under general anesthesia during which the dexmedetomidine infusion was continued. A healthy baby boy was delivered with normal Apgar scores and no discernible neurobehavioral or other deficits.
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Affiliation(s)
- Andrea Kurz
- Department of Outcomes Research, The Cleveland Clinic, 9500 Euclid Avenue, P77 Cleveland, Ohio 44195, USA.
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Jeon YT, Jeon YS, Kim YC, Bahk JH, Do SH, Lim YJ. Intrathecal clonidine does not reduce post-spinal shivering. Acta Anaesthesiol Scand 2005; 49:1509-13. [PMID: 16223398 DOI: 10.1111/j.1399-6576.2005.00783.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND After general or epidural anesthesia, clonidine is known to be effective in suppressing established shivering. The aim of this study was to assess the preventive effect of intrathecal clonidine on post-spinal shivering compared with intravenous (i.v.) clonidine. METHODS One hundred and fifty patients scheduled for orthopedic surgery were randomly allocated into three groups to receive either 1 microg/kg clonidine i.v. (IV group) or the same volume of isotonic saline (control and IT groups) at 5 min before spinal anesthesia. Spinal anesthesia was performed with 12-15 mg hyperbaric bupivacaine 0.5% plus either 1 ml of saline (control and IV groups) or 150 microg clonidine (IT group). Shivering was evaluated for a period of 90 min and graded as none, mild, moderate, and severe. RESULTS Twenty patients (40%) in the control group and 17 patients (34%) in the IT group showed shivering compared with four (8%) in the IV group. Patients with moderate-to-severe shivering were only seen in the control and IT group, and the maximal intensity of shivering was not different between the two groups. Patients in the IV group were significantly more sedated than the other groups. CONCLUSIONS The intrathecal administration of clonidine 150 microg fails to prevent post-spinal shivering; by contrast, we have confirmed that i.v. clonidine 1 microg/kg is an effective method to prevent shivering in patients undergoing spinal anesthesia for orthopedic surgery.
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Affiliation(s)
- Y T Jeon
- Department of Anesthesiology, Seoul National University Bundang Hospital, Seognam, Seoul, South Korea
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Abstract
Although hypothermia has been reported during epidural anesthesia performed for nonobstetrical surgery or cesarean section, epidural analgesia for labor may lead to hyperthermia. Its incidence, time-course and intensity are influenced by multiple factors including site of measurement, duration of labor preceding epidural analgesia and perhaps ambient temperature and occurrence of shivering. During the first 2-5 h of epidural analgesia, a significant increase in temperature is not usually observed. Then, if labor is prolonged (mostly in primiparas), temperature may increase at a rate of 0.07-0.15 degrees C per hour. Imbalance between reduced heat loss during epidural analgesia and labor-induced heat production has been implicated but impairment of central temperature regulation cannot be excluded. This hyperthermia is usually of mild intensity (< 38 degrees C) and occurs in the absence of any infectious process; maternal and fetal consequences are also usually absent and treatment is probably unnecessary. However, fetal tachycardia may occur and the potential for a deleterious effect on the fetus remains controversial. Various measures for cooling the mother have been proposed but their efficacy has not been evaluated. The recognition that epidural analgesia may provoke hyperthermia may help to avoid inappropriate use of antibiotics or fetal extraction.
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Affiliation(s)
- F J Mercier
- Département d'Anesthesie-Reanimation, Hôpital Antoine Beclere, Clamart Cedex, France
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Kranke P, Eberhart LHJ, Roewer N, Tramèr MR. Postoperative shivering in children: a review on pharmacologic prevention and treatment. Paediatr Drugs 2003; 5:373-83. [PMID: 12765487 DOI: 10.2165/00128072-200305060-00003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Postoperative shivering consists of muscular tremor and rigidity. It is often associated with body heat loss, although hypothermia alone does not fully explain the occurrence of shivering. Shivering is self-limiting, never becomes chronic, and is rarely associated with major morbidity. However, it affects the comfort of the patients, and may sometimes lead to more serious complications. The efficacy of a great variety of pharmacologic interventions to prevent shivering and to treat established symptoms has been tested in randomized controlled trials. These can be gathered systematically; recommendations on prevention and treatment can then be based on the strongest evidence. Unfortunately all these trials have been performed in adults. Thus, recommendations for the control of postoperative shivering in children have to be extrapolated from adult data. In adults, a systematic review strongly suggests that simple measurements are efficacious for both prevention and treatment. For prevention, extrapolation of these adult data indicates that three children have to receive intravenous clonidine 1.5 micro g/kg during anesthesia for one not to shiver, when they would have done so had they not received clonidine. For this degree of efficacy, the expected incidence of shivering (baseline risk) has to be high (approximately 50%). For treatment, extrapolation from adult data indicates that less than two children need to receive intravenous meperidine (pethidine) 0.35 mg/kg, or clonidine 1.5 micro g/kg for one to stop shivering five minutes after drug administration, when they would not have done so had they not received one of these drugs. Since the treatment of established shivering is efficacious, simple, inexpensive, and relatively safe, and since prevention is only efficacious if the baseline risk is very high, we recommend the 'wait and see' strategy.
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Affiliation(s)
- Peter Kranke
- Department of Anesthesiology, University of Würzburg, Würzburg, Germany.
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Paech MJ, Banks SL, Gurrin LC, Yeo ST, Pavy TJG. A randomized, double-blinded trial of subarachnoid bupivacaine and fentanyl, with or without clonidine, for combined spinal/epidural analgesia during labor. Anesth Analg 2002; 95:1396-401, table of contents. [PMID: 12401632 DOI: 10.1097/00000539-200211000-00054] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED Subarachnoid clonidine may increase the duration of spinal opioid and local anesthetic analgesia during labor, but it may also increase hypotension and sedation, and the therapeutic range is unclear. We studied 110 term parturients of mixed parity having combined spinal/epidural analgesia during labor in this randomized, double-blinded trial. All received subarachnoid fentanyl 20 micro g and bupivacaine 2.5 mg, plus either saline or clonidine (15, 30, or 45 micro g). Of 101 per-protocol parturients (n = 25, 24, 26, and 26 in Groups C0, C15, C30, and C45, respectively), 22 delivered before the cessation of spinal analgesia. Group demographics and pain scores from Time 0 to 120 min were similar. There was no significant difference among groups in the duration of spinal analgesia (P = 0.09) or in the duration of clonidine groups combined compared with control (median, 120 min [interquartile range, 96-139 min] versus 98 min [80-120 min]; P = 0.07). Systolic blood pressure was significantly lower in all clonidine groups between 40 and 90 min (P = 0.001). Hypotension (P = 0.05) and the requirement for ephedrine (P = 0.02) were dose dependent, but groups had a similar incidence of hypotension. The addition of clonidine 15-45 micro g to subarachnoid fentanyl and bupivacaine reduced blood pressure and did not significantly increase the duration of spinal analgesia. IMPLICATIONS The addition of 15-45 micro g of clonidine to subarachnoid fentanyl plus bupivacaine did not significantly increase the duration of spinal analgesia but did decrease maternal blood pressure. The results of this study do not support the use of subarachnoid clonidine to prolong the action of spinal labor analgesia when fentanyl plus bupivacaine are administered.
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Affiliation(s)
- Michael J Paech
- Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, 374 Bagot Road, Subiaco 6008 WA, Australia.
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Kranke P, Eberhart LH, Roewer N, Tramèr MR. Pharmacological Treatment of Postoperative Shivering: A Quantitative Systematic Review of Randomized Controlled Trials. Anesth Analg 2002. [DOI: 10.1213/00000539-200202000-00043] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kranke P, Eberhart LH, Roewer N, Tramèr MR. Pharmacological treatment of postoperative shivering: a quantitative systematic review of randomized controlled trials. Anesth Analg 2002; 94:453-60, table of contents. [PMID: 11812718 DOI: 10.1097/00000539-200202000-00043] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Shivering is a frequent complication in the postoperative period. The relative efficacy of interventions that are used for the treatment of postoperative shivering is not well understood. We performed a systematic search (MEDLINE, EMBASE, Cochrane Library, hand searching, all languages, to August, 2000) for full reports of randomized comparisons of any pharmacological antishivering intervention (active) with placebo (control) in the postoperative period. Dichotomous data on absence of further shivering after treatment and adverse effects were extracted from original reports. Relative risk (RR) and number-needed-to-treat (NNT) were calculated with 95% confidence interval (CI) using a fixed effect model. Data from 20 trials (944 adults received an active intervention, 413 were controls) were analyzed. Antishivering efficacy depended on the active regimen and the length of follow-up. Efficacy with meperidine 25 mg, clonidine 150 microg, ketanserin 10 mg, and doxapram 100 mg was reported in at least three trials; all were significantly more effective than control. After 1 min, the NNT of meperidine 25 mg for no further shivering compared with placebo was 2.7 (RR, 6.8; 95% CI, 2.5-18.5). After 5 min, the NNT of meperidine 25 mg was 1.3 (RR, 9.6; 95% CI, 5.7-16), the NNT of clonidine 150 microg was 1.3 (RR, 6.8; 95% CI, 3.3-14.2), the NNT of doxapram 100 mg was 1.7 (RR 4.0; 95% CI, 2.4-6.5), and the NNT of ketanserin 10 mg was 2.3 (RR 3.1; 95% CI, 1.9-5.1). After 10 min, the NNT of meperidine 25 mg was 1.5 (RR 4.0; 95% CI, 2.5-6.2). After 15 min, the NNT of ketanserin 10 mg was 3.3 (RR 1.5; 95% CI, 1.2-1.9). Long-term outcome data were lacking. There were not enough data for alfentanil, fentanyl, morphine, nalbuphine, lidocaine, magnesium, metamizol, methylphenidate, nefopam, pentazocine, and tramadol to draw meaningful conclusions. Reporting of adverse drug reactions was sparse. Fewer than two shivering patients need to be treated with meperidine 25 mg, clonidine 150 microg, or doxapram 100 mg for one to stop shivering within 5 min who would have continued to shiver had they all received a placebo. IMPLICATIONS Less than two shivering patients need to be treated with meperidine 25 mg, clonidine 150 microg, or doxapram 100 mg for one to stop shivering within 5 min who would have continued to shiver had they all received a placebo.
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Affiliation(s)
- Peter Kranke
- Department of Anesthesiology, University of Würzburg, Germany.
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Ravid D, Gidoni Y, Bruchim I, Shapira H, Fejgin MD. Postpartum chills phenomenon: is it a feto-maternal transfusion reaction? Acta Obstet Gynecol Scand 2001; 80:149-51. [PMID: 11167210 DOI: 10.1034/j.1600-0412.2001.080002149.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To examine the theory that the postpartum shivering phenomenon is related to feto-maternal bleed during the third stage of labor. METHODS One hundred laboring low-risk women who had a normal vaginal delivery were observed for the presence of postpartum chills. The duration of the first and second stages of labor changes in body temperature, maternal and fetal blood types and the use of epidural anesthesia were recorded. Following the delivery maternal blood was examined for the presence of fetal red blood cells using the Kleihauer-Betke stain. RESULTS Complete data was available in 97 patients. Post-partum chills occurred in 31 of them (32%). Women with and without chills were similar in their maternal and gestational age, the use of epidural anesthesia, and length of second stage of labor. Women with chills delivered smaller babies but the difference did not reach significance. Maternal-fetal blood group incompatibility was significantly more common among shivering than non-shivering women (48% vs. 20% respectively, p=0.006). Kleihauer-Betke test was positive in 11 women. The only two women in this group who experienced chills had maternal-fetal blood group incompatibility. CONCLUSION Post-partum chills are a common phenomenon. It may be the clinical presentation of feto-maternal transfusion reaction. The small number of positive Kleihauer-Betke tests may reflect its low sensitivity in the detection of small feto-maternal bleeds.
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Affiliation(s)
- D Ravid
- Department of Obstetrics and Gynecology, Meir Hospital, Kfar-Saba, Israel
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Bock M, Kunz P, Martin E, Motsch J. Intravenous or caudal clonidine does not influence core temperature in children. J Therm Biol 2000. [DOI: 10.1016/s0306-4565(99)00037-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Affiliation(s)
- D I Sessler
- Department of Anesthesia, University of California, San Francisco 94143-0648, USA
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Horn EP, Werner C, Sessler DI, Steinfath M, Schulte am Esch J. Late intraoperative clonidine administration prevents postanesthetic shivering after total intravenous or volatile anesthesia. Anesth Analg 1997; 84:613-7. [PMID: 9052312 DOI: 10.1097/00000539-199703000-00028] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Postoperative administration of clonidine is an effective treatment for shivering. However, the ability of this drug to stop postanesthetic shivering when administered intraoperatively remains controversial. Furthermore, the relative efficacy of clonidine during isoflurane and propofol anesthesia remains unknown. We therefore evaluated the incidence of postanesthetic shivering in patients given clonidine during nitrous oxide/isoflurane or propofol anesthesia. Because clonidine is an analgesic, we also evaluated postoperative pain and analgesic requirements. We studied 60 patients undergoing elective ear or nose surgery. General anesthesia was induced with 2.0 mg/kg propofol, 1.5 micrograms/kg fentanyl, and 0.1 mg/kg vecuronium. General anesthesia was maintained with isoflurane and 70% nitrous oxide in one group of patients; in the other, a continuous infusion of propofol (8 mg.kg-1.h-1) was administered (without nitrous oxide). Five minutes before tracheal extubation, patients in each group were randomly assigned to receive saline, placebo, or 3 micrograms/kg clonidine intravenously. Postanesthetic shivering was evaluated by a blind investigator. Postoperative pain was assessed using a visual analog scale. Postoperative shivering was observed in 53% of the patients given isoflurane without clonidine and in 13% of the patients given propofol without clonidine. No patient given clonidine shivered. Clonidine administration significantly reduced postoperative pain. The incidence of postanesthetic shivering was significantly less after propofol anesthesia than after isoflurane/nitrous oxide anesthesia. However, a late intraoperative bolus administration of 3 micrograms/kg clonidine prevents postoperative shivering in patients given either type of anesthesia.
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Affiliation(s)
- E P Horn
- Department of Anesthesiology, University Hospital Eppendorf, Hamburg, Germany
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Takahashi H, Nishikawa T, Mizutani T, Handa F. Oral clonidine premedication decreases energy expenditure in human volunteers. Can J Anaesth 1997; 44:268-72. [PMID: 9067045 DOI: 10.1007/bf03015364] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Clonidine not only stops postoperative shivering and decreases oxygen consumption, but also decreases energy expenditure with or without a reduction in shivering during recovery from anaesthesia. It is important to see if clonidine decreases energy expenditure at rest since this may contribute to a postoperative decrease in energy expenditure. The authors tested the hypothesis that oral clonidine decreases energy expenditure at rest. METHODS Twenty healthy male volunteers were randomly assigned to one of two groups. Ten volunteers received oral clonidine approximately 5 micrograms.kg-1 (clonidine group), while the remaining 10 volunteers received placebo (control group). Blood pressure, heart rate, body temperature at the tympanic membrane, sedation score graded from 1 (alert) to 5 (sleeping and difficult to be aroused by tactile stimulation) were measured before and at 30-min intervals for three hours after administration of clonidine or placebo. Measurements of energy expenditure and respiratory quotient were made with a head canopy system at one-minute intervals and averaged over 15 min before, and at 30, 60, 90, 120, and 180 min after administration of clonidine or placebo. RESULTS Sedation score increased from 1 to 3 (median) after clonidine administration. Energy expenditure decreased from 1452 +/- 225 kcal.24hr-1 (mean +/- SD) at baseline to 1258 +/- 175 kcal.24hr-1 at 180 min after clonidine administration (P < 0.05). CONCLUSION This study suggests that oral clonidine at a dose of 5 micrograms.kg-1 decreases energy expenditure at rest.
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Affiliation(s)
- H Takahashi
- Department of Anaesthesiology, Institute of Clinical Medicine, University of Tsukuba, Japan.
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Horn EP, Werner C, Sessler DI, Steinfath M, am Esch JS. Late Intraoperative Clonidine Administration Prevents Postanesthetic Shivering After Total Intravenous or Volatile Anesthesia. Anesth Analg 1997. [DOI: 10.1213/00000539-199703000-00028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Capogna G, Celleno D. Improving epidural anesthesia during cesarean section: causes of maternal discomfort or pain during surgery. Int J Obstet Anesth 1994; 3:149-52. [PMID: 15636939 DOI: 10.1016/0959-289x(94)90228-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- G Capogna
- Department of Anesthesiology, Fatebenefratelli General Hospital, Isola Tiberina, Rome, Italy
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