Thiopental-Rocuronium Versus Ketamine-Rocuronium for Rapid-Sequence Intubation in Parturients Undergoing Cesarean Section

Perioperative management of emergent cesarean section in a patient with peripartum cardiomyopathy and orthopnea: a case report

Perioperative management of pregnant women with heart failure is difficult. Management of anesthesia in pregnant women is especially difficult because all of the currently available choices present challenges. We report a patient with peripartum cardiomyopathy (PPCM) who required an emergent cesarean section and discuss the possible tactics for managing anesthesia. A 40-year-old primipara with severe cardiac and respiratory failure required an emergent cesarean section at 39⁺¹ gestational weeks. Her left ventricular ejection fraction was between 10% and 15%, and she had orthopnea. General anesthesia was planned after inserting sheaths for percutaneous cardiopulmonary support from the femoral artery and vein. However, when the patient was asked to lie down on the operation bed, she panicked and resisted because of labor pain and dyspnea. Therefore, anesthesia was induced instead of the initial plan. Finally, we successfully managed the anesthesia and delivered the newborn. There are no alternatives to general anesthesia in patients with PPCM presenting with orthopnea. Anesthesia induction in the supine position is impossible in such patients owing to dyspnea. Anesthesia should be started with light sedation in the sitting position, and ketamine or low-dose remifentanil may be an option to maintain maternal hemodynamics and prevent neonatal asphyxia.

Intubation Conditions following Rocuronium: Influence of Induction Agent and Priming

A small priming dose of rocuronium can shorten the onset time of neuromuscular blockade. Induction agents with less cardiovascular depression also reduce the onset time. We hypothesized that ketamine, compared to thiopentone, would reduce onset time and improve intubating conditions following priming. Sixty patients ASA I to II, randomized by computer-generated sequence to four groups were investigated in a double-blind controlled trial. In the two groups with priming, 0.04 mg/kg of rocuronium was followed by three minutes of priming interval. Induction was followed by an intubation dose of 0.4 mg/kg of rocuronium. After 30 seconds, intubation was attempted within a further 20 seconds. In the two control groups, the same sequence was repeated except sham priming (saline) was given. For induction, S-ketamine (1 mg/kg) or thiopentone (4 mg/kg) were administered. Intubating conditions were graded as excellent, good, poor, or not possible. Neuromuscular transmission was monitored by acceleromyography of the thumb. There were no measured differences in onset time of neuromuscular block or in haemodynamics between the groups. The proportion of good to excellent intubating conditions was higher when ketamine was preceded by priming compared to ketamine without priming (87% vs 20%; P<0.05). In both priming and control groups intubating conditions were improved when using ketamine compared to thiopentone (P<0.05). The mechanism of this effect was not clear from this study.

The Pregnant Trauma Patient

Trauma is the leading non-obstetric cause of maternal death. Optimal management of the pregnant trauma patient requires a multidisciplinary approach. The anaesthetist and critical care physician play a pivotal role in the entire continuum of fetomaternal care, from initial assessment, resuscitation and intraoperative management, to postoperative care that often involves critical care support and patient transfer. Primary goals are aggressive resuscitation of the mother and maintenance of uteroplacental perfusion and fetal oxygenation by the avoidance of hypoxia, hypotension, hypocapnia, acidosis and hypothermia. Recognizing and understanding the mechanisms of injury, the factors that may predict fetal outcome, and the pathophysiological changes that can result from trauma, will allow early identification and treatment of fetomaternal injury. This in turn should improve morbidity and mortality. A framework for the acute care of the pregnant trauma patient is presented.

Rapid Sequence Induction and Intubation

The modern version of RSI starts with preoxygenation. General anaesthesia is then induced using a rapid acting intravenous anaesthetic and a rapid acing muscle relaxant. Cricoid pressure is applied by an experienced assistant during induction, which should then be maintained until the trachea of the patient is intubated, correct positioning of the tracheal tube confirmed and the cuff inflated. The patient is conventionally not ventilated during this phase but critically ill patients are exceptions. The patient's tracheal should be intubated when adequately paralysed and its position verified. The assistant can then relieve the cricoid pressure and the tracheal tube fixed.

Impalement Thoracoabdominal Trauma Secondary to Falling on Metallic (Iron) Bars: An Extremely Rare and Unique Case

Introduction

Penetrating thoracoabdominal injuries are potentially life threatening due to the associated hemorrhagic shock and visceral injury. Through and through penetrating injury with polytrauma is rarely encountered.

Case Presentation

Here we report on a 25-year-old male with penetrating thoracoabdominal injury caused by a metallic (iron) bar projecting from a pillar of a construction site after he fell down from a height.

Conclusions

Anesthetic and surgical management was difficult due to the inability to position in supine and rapidly progressing hemorrhagic shock. Surgical management for extraction of this iron bar and intensive monitoring and resuscitation resulted in an uneventful successful outcome.

Intravenous ketamine during spinal and general anaesthesia for caesarean section: systematic review and meta-analysis

BACKGROUND

Intravenous ketamine has been used during general and regional anaesthesia for caesarean section. No systematic review and meta-analysis on the desired effects and adverse effects of ketamine administration during caesarean section have yet been performed.

METHODS

After a systematic literature search a meta-analysis was conducted with the random effects model. Weighted mean difference (WMD) or risk ratio and 95% confidence intervals (CIs) were computed.

RESULTS

Twelve randomised controlled double-blind trials comprising 953 patients were included: seven studies reported on spinal anaesthesia and five on general anaesthesia. Significant differences in the aforementioned outcome variables were found only in the spinal anaesthesia studies. In the spinal anaesthesia studies the time to the first analgesic request was significantly longer in ketamine-treated women, the WMD was 49.36 min (95% CI 43.31-55.41); visual analogue scale pain scores at rest 2 h after surgery were significantly lower. No differences were observed for maternal nausea, vomiting, pruritus, and psychomimetic effects. Only few data were found for neonatal outcomes.

CONCLUSIONS

We conclude that ketamine enhances post-operative analgesia after caesarean section under spinal anaesthesia. There is a paucity of data for several maternal adverse effects as well as for neonatal well-being. Further studies are needed for general anaesthesia.

The effect of low dose ketamine and priming of cisatracurium on the intubating condition and onset time of cisatracurium

Background

Both ketamine and priming may accelerate the onset time of neuromuscular blocking agents. We investigate the effect of low dose ketamine and cisatracurium priming on the intubating condition and onset time of cisatracurium.

Methods

After Institutional Review Board approval, 120 consecutive patients undergoing general anesthesia were randomly assigned to one of 4 groups. All patients were injected one of normal saline (group C), cisatracurium 0.01 mg/kg (group P), ketamine 0.5 mg/kg (group K) and combination of cisatracurium 0.01 mg/kg, and ketamine 0.5 mg/kg (group PK) diluted into a 5 ml solution, followed 3 minutes later by cisatracurium 0.15 mg/kg in group C and K, and 0.14 mg/kg cisatracurium in priming group. Onset time was recorded the electromyographical responses using single twitch and intubating conditions were evaluated at 60 seconds after cisatracurium administration.

Results

The mean onset time was most significantly accelerated in Group PK and was also significantly more accelerated in Group P and K compared with Group C (P < 0.008). It was 112.7 ± 13.2, 91.4 ± 17.9, 84.9 ± 12.7 and 76.4 ± 8.3 seconds in Group C, P, K, and PK, respectively. Intubating conditions were significantly improved in Group P, K and PK than Group C (P < 0.008). Especially, Group PK showed most significant improvement of intubating conditions.

Conclusions

The combination of the low dose ketamine and cisatracurium priming accelerated the onset time and was improved the intubating conditions.

Scandinavian clinical practice guidelines on general anaesthesia for emergency situations

Emergency patients need special considerations and the number and severity of complications from general anaesthesia can be higher than during scheduled procedures. Guidelines are therefore needed. The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine appointed a working group to develop guidelines based on literature searches to assess evidence, and a consensus meeting was held. Consensus opinion was used in the many topics where high-grade evidence was unavailable. The recommendations include the following: anaesthesia for emergency patients should be given by, or under very close supervision by, experienced anaesthesiologists. Problems with the airway and the circulation must be anticipated. The risk of aspiration must be judged for each patient. Pre-operative gastric emptying is rarely indicated. For pre-oxygenation, either tidal volume breathing for 3 min or eight deep breaths over 60 s and oxygen flow 10 l/min should be used. Pre-oxygenation in the obese patients should be performed in the head-up position. The use of cricoid pressure is not considered mandatory, but can be used on individual judgement. The hypnotic drug has a minor influence on intubation conditions, and should be chosen on other grounds. Ketamine should be considered in haemodynamically compromised patients. Opioids may be used to reduce the stress response following intubation. For optimal intubation conditions, succinylcholine 1-1.5 mg/kg is preferred. Outside the operation room, rapid sequence intubation is also considered the safest method. For all patients, precautions to avoid aspiration and other complications must also be considered at the end of anaesthesia.

Ketamine, but not priming, improves intubating conditions during a propofol-rocuronium induction

PURPOSE

Both ketamine and priming may shorten the onset time of rocuronium. This study investigates the effects of ketamine and priming as components of a propofol induction on intubating conditions and onset of neuromuscular block.

METHODS

This prospective randomized double-blind study was performed in 120 American Society of Anesthesiologists (ASA) I-II patients who were assigned to one of four groups of 30 patients each: control, priming, ketamine, and ketamine-priming. Ketamine 0.5 mg x kg(-1) or saline was given before priming and induction. Rocuronium 0.06 mg x kg(-1) or saline was injected 2 min before propofol 2.5 mg x kg(-1). This was followed by rocuronium 0.6 mg x kg(-1) or by rocuronium 0.54 mg x kg(-1) if priming was given. Intubation was performed one minute later. Intubating conditions were graded as excellent, good, or poor. Heart rate, noninvasive blood pressure, and train-of-four (TOF) response were monitored.

RESULTS

Intubating conditions were graded excellent in 20% of the control group, 30% of the priming group, 47% of the ketamine group, and 57% of the ketamine-priming group. Analysis using forward stepwise regression indicated that ketamine improved intubating conditions (P = 0.001) but priming did not (P = 0.35). Time to reach a TOF count of zero was shortened by ketamine (P = 0.001) but not by priming (P = 0.94): 216 +/- 20 s in the control group, 212 +/- 27 s in the priming group, 162 +/- 18 s in the ketamine group, and 168 +/- 22 s in the ketamine-priming group.

CONCLUSION

A low-dose ketamine used with a propofol-rocuronium induction improved intubating conditions and shortened onset time. Priming did not influence intubating conditions or onset time.

Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent?

In rapid sequence induction of anaesthesia in the emergency setting in shocked or hypotensive patients (e.g. ruptured abdominal aortic aneurysm, polytrauma or septic shock), prior resuscitation is often suboptimal and comorbidities (particularly cardiovascular) may be extensive. The induction agents with the most favourable pharmacological properties conferring haemodynamic stability appear to be ketamine and etomidate. However, etomidate has been withdrawn from use in some countries and impairs steroidogenesis. Ketamine has been traditionally contra-indicated in the presence of brain injury, but we argue in this review that any adverse effects of the drug on intracranial pressure or cerebral blood flow are in fact attenuated or reversed by controlled ventilation, subsequent anaesthesia and the greater general haemodynamic stability conferred by the drug. Ketamine represents a very rational choice for rapid sequence induction in haemodynamically compromised patients.

The effect of ephedrine on intubating conditions and haemodynamics during rapid tracheal intubation using propofol and rocuronium

BACKGROUND

We compared the effect of pre-treatment with ephedrine 75, 100, 150 microg kg(-1) and saline on intubating conditions and haemodynamics during rapid tracheal intubation using propofol and rocuronium.

METHODS

One hundred adult patients randomized into one of the four groups-PE 75, PE 100, PE 150, and saline (control) groups-were pre-treated with i.v. ephedrine 75, 100, 150 microg kg(-1) or saline, respectively, 1 min before rapid tracheal intubation using propofol 2.5 mg kg(-1) and rocuronium 0.6 mg kg(-1). A blinded anaesthesiologist assessed the intubating conditions. Heart rate and mean arterial pressure were recorded before anaesthesia induction (baseline), post-induction, and every minute after intubation for 5 min. A 20% change in haemodynamic variables from baseline was regarded as clinically significant. Data were analysed using anova test with post hoc Tukey's test and chi2 or Fisher's exact test. P < 0.05 was regarded as significant.

RESULTS

Patient characteristics, baseline heart rate, and mean arterial pressure were comparable between the groups. Intubating conditions were significantly better in the PE 75 (P = 0.003) and PE 100 (P = 0.001) groups. A significant increase in heart rate was observed in the PE 75 and PE 150 groups when compared with the saline group. A statistically significant difference in mean arterial pressure was noted between PE 75 and PE 150 groups and between PE 150 and saline groups at most of the time intervals. However, when considering the clinical significance of these, all groups were comparable (P > 0.05).

CONCLUSIONS

Ephedrine either 75 or 100 microg kg(-1) given before rapid tracheal intubation using propofol and rocuronium bromide improves the intubation conditions. It is not effective in preventing the hypotension which follows ensuing induction of anaesthesia.

Prise en charge anesthésique de la femme enceinte pour cœliochirurgie gynécologique non obstétricale à la maternité de Clermont-Ferrand

OBJECTIVE

To evaluate the anaesthetic management intended for pregnant women in the field of non obstetric and gynaecologic laparoscopic surgery.

STUDY DESIGN

Retrospective and monocentric investigation.

PATIENTS AND METHODS

Analysis of the anaesthetic and obstetric files from 27 pregnant women operated on in the establishment, between January 2001 and July 2004.

RESULTS

27 female patients involved in the study. The mean pregnancy term was 15 weeks when laparoscopic surgery was performed, though a single patient was at 30 weeks. The average duration of the surgery was 61 minutes, of which 28 minutes were dedicated to pneumoperitoneum. Twenty-four patients underwent general anaesthesia, the three others underwent locoregional anaesthesia. During the perioperative period no surgical, anaesthetic or obstetric complications were observed.

CONCLUSION

Laparoscopic surgery during pregnancy requires double skilled management, both in anaesthesiology and obstetrics. On haemodynamics and breathing, pneumoperitoneum does not induce any additional effects when compared to operations without pregnancy. Except with delivery cases, anaesthetic support in laparoscopic surgery intended for pregnant women eventually does not generate any specific problems, but requires the same rigorous management as the one usually following surgery for pregnant patients.

Controversies in rapid sequence intubation in children

PURPOSE OF REVIEW

Rapid sequence intubation is the method of choice for intubation of the emergency department patient. The purpose of the present review is to address several controversies pertaining to emergency department rapid sequence intubation of children.

RECENT FINDINGS

The topics covered in this review include the determination of the appropriate clinician to perform emergency department intubation, the use of atropine and lidocaine as premedications, the choice of sedative agents depending upon the clinical scenario, and the choice of neuromuscular blockade agent. Concerning these topics: The literature supports that emergency department physicians, with appropriate training, successfully perform intubation in most patients. Limited data exist to determine the appropriate use of atropine and lidocaine for rapid sequence intubation. Etomidate has clearly become a preferred sedative for rapid sequence intubation with a low risk of cardiovascular side effects. Thiopental and propofol may more readily provide adequate sedation as compared with etomidate but both have the potential to reduce blood pressure. Succinylcholine arguably remains the preferred neuromuscular blockade agent for rapid sequence intubation in most children. The side effects of succinylcholine occur in relatively predictable circumstances. Rocuronium is a commonly used nondepolarizing paralytic agent but its prolonged duration of action must be weighed against the risk of side effects associated with succinylcholine.

SUMMARY

Though more research is needed, the available data allow for the development of protocols that will result in a rational, scenario-based approach to rapid sequence intubation in children.

Influence of induction of anaesthesia on intubating conditions one minute after rocuronium administration: comparison of ketamine and thiopentone

We compared the effect of thiopentone and ketamine on intubating conditions after rocuronium 0.6 mg.kg-1 in two groups of patients (n = 16 each), aged 21-44 years, undergoing elective surgery. Premedication consisted of alprazolam 1 mg by mouth 1 h before surgery. All patients received midazolam 2 mg intravenously 2 min before intravenous administration of thiopentone 5 mg.kg-1 or ketamine 2.5 mg.kg-1. Muscle relaxation was provided by rocuronium 0.6 mg.kg-1. One minute after rocuronium administration, tracheal intubation was performed within 15 s by a skilled anaesthetist blinded to the treatment group assignment. Intubating conditions were graded as excellent, good, fair or poor on the basis of jaw relaxation, position of vocal cords and diaphragmatic response. Neuromuscular transmission was assessed at the adductor pollicis muscle using a TOF-GUARD monitor. Excellent and good intubating conditions were obtained in 100% of patients in the ketamine group and in 50% of patients in the thiopentone group (p = 0.002). Jaw relaxation was similar in both groups but vocal cord conditions were better and the diaphragmatic response less marked in the ketamine group compared with the thiopentone group (p = 0.002). The degree of neuromuscular block [% decrease of T1, mean (SD)] at the time of intubation was similar: 51.8 (25)% (ketamine group) and 54.3 (23.1)% (thiopentone group). We conclude that ketamine 2.5 mg.kg-1 provides better intubating conditions than thiopentone 5 mg.kg-1 1 min after administration of rocuronium 0.6 mg.kg-1.

Effects of maternal anesthesia in the neonate

All commonly used anesthetic agents and drugs undergo placental transfer. Understanding the placental transfer of anesthetic drugs and their effects on the neonate is essential for optimal administration of both regional and general anesthesia. Regional anesthesia is decidedly safer for the mother and, when properly performed, actually may be beneficial to the stressed neonate. The healthy neonate also benefits from maternal analgesia during labor and delivery. General anesthesia may result in transient neonatal depression, particularly when delivery is of an emergency nature. The skill and knowledge of the anesthesiologist are more important than the type of anesthesia administered. Therefore, when properly performed, both regional and general anesthesia are quite safe in terms of neonatal outcome.