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Query: UMLS:C0344307 (analgesia)
 28,200 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The use of intravenous (i.v.) patient-controlled fentanyl analgesia during labour in a parturient with unexplained thrombocytopenia (70 x 10(3).ml-1) is described. The patient self-administered boluses of 25 micrograms of fentanyl with a lock-out interval of ten min. In addition, a concurrent fentanyl infusion of 25 micrograms.hr-1 was given. Effective analgesia was achieved during labour and a total of 1025 micrograms of fentanyl was infused over 11 hr 55 min until delivery of a vigorous infant with Apgar scores of 9 after one and five min. Respiratory depression or undue sedation were not observed in the mother either during labour or in the post-partum period. At birth, maternal total plasma fentanyl concentration was 1.11 ng.ml-1, whereas neonatal umbilical total plasma fentanyl concentration was 0.43 ng.ml-1. Newborn plasma protein binding of fentanyl was lower compared to the mother (63% vs 89%). Thus, free fentanyl concentrations (0.16 ng.ml-1) were identical in the mother and newborn at delivery.
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PMID:Maternal and fetal effects of intravenous patient-controlled fentanyl analgesia during labour in a thrombocytopenic parturient. 129 46

A questionnaire survey of current practice at a small cross-section of obstetric units, covering 22% of all United Kingdom deliveries, revealed a marked lack of standard practice regarding requests for coagulation screens on pre-eclamptic patients who require epidural procedures. A retrospective audit was therefore carried out on 434 coagulation screens requested for pre-eclamptic patients in whom epidural analgesia might have been considered. Borderline abnormalities of coagulation were found in only 10 patients (2%). Platelet counts of less than 150 x 10(9)/litre were present in 28% of cases. 'Significant' thrombocytopenia (less than 100 x 10(9)/litre) and all coagulation abnormalities were only encountered in severe pre-eclampsia (diastolic blood pressure of greater than 110 mmHg and proteinuria of + + or greater). Furthermore, coagulation abnormality was always associated with a reduced platelet count (mean, 97 x 10(9)/litre). This study would therefore support anaesthetic practice which restricted any requests for coagulation testing to severe pre-eclamptic patients only. For these patients first line testing could be limited to a platelet count.
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PMID:Coagulation screening before epidural analgesia in pre-eclampsia. 186 17

The anaesthetic management for Caesarean delivery is described in a patient with May-Hegglin anomaly. The condition, which is inherited as an autosomal dominant characteristic, has features of thrombocytopenia and a bleeding diathesis. Labour was induced and she received type specific platelet transfusion. Spinal anaesthesia, using five per cent lidocaine, 75 mg, with epinephrine and 0.5 mg morphine sulphate produced satisfactory operating conditions, excellent postoperative analgesia, and uncomplicated initial recovery.
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PMID:Anaesthesia for caesarean delivery in a patient with May-Hegglin anomaly. 272 Aug 71

Platelet count and bleeding time and the correlation between these two variables in women with preeclampsia who received epidural or general anesthesia for cesarean section were evaluated. The study included 106 women with preeclampsia who were undergoing cesarean section and 94 healthy, term parturients receiving epidural anesthesia for labor analgesia or for cesarean section. Platelet counts were measured using an automated Coulter Counter, and bleeding times were measured using the modified Ivy bleeding time technique. Platelet count was significantly lower and bleeding time significantly prolonged in patients with preeclampsia compared with the control group (P less than 0.0001). In the preeclampsia group, eight patients (7.5%) had thrombocytopenia (platelet count less than 100,000/mm3), whereas in the control group, all women had a normal platelet count (greater than 150,000/mm3). All but one patient with thrombocytopenia had prolonged bleeding time. In addition, 34% of those women with severe preeclampsia and 13% with mild preeclampsia had prolonged bleeding time, although their platelet count was adequate. In the control group, 2% had abnormal bleeding time in the presence of a normal platelet count. There was good correlation between bleeding time and platelet count only when platelet count was lower than 100,000/mm3 (r = -0.76, P less than -0.02).
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PMID:Correlation between bleeding times and platelet counts in women with preeclampsia undergoing cesarean section. 275 43

We report a 21-year-old male patient suffering from acute myeloid leukemia and concomitant thrombocytopenia. Following a diagnostic thoracotomy-which revealed Aspergillus pneumonia-he developed respiratory insufficiency and dyspnea. A thoracic epidural catheter was inserted and epidural morphine treatment led to improved ventilation. No clinical signs of pathological epidural processes were noticed during the treatment. The patient died of Aspergillus sepsis 26 days after catheter insertion. Autopsy revealed bacterial growth in the epidural space with slight infectious tissue reactions as well as an epidural hematoma. No evidence of spinal cord compression was found at autopsy. The development of epidural infection or hematoma seems to be a possible complication of epidural analgesia in patients suffering from impaired defense mechanisms or thrombocytopenia. These risk factors should be taken into account when epidural analgesia is considered. We suggest that the platelet count should be determined beforehand in patients suspected of having thrombocytopenia (e.g. cancer, pre-eclampsia).
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PMID:[Epidural hematoma following epidural catheter anesthesia in thrombocytopenia]. 335 26

Eighteen patients with multiple myeloma were treated by hemibody irradiation using large single fractions, usually to a dose of 10 Gy (lower half) and 7.5 Gy (upper half). All except one patient had previously been treated by multiple courses of conventional chemotherapy with melphalan and prednisone, and were considered to be resistant to further chemotherapy. In most cases, local field irradiation had also been given for symptomatic bone pain. Of the 13 patients who had symptoms at the start of hemibody irradiation, 11 improved sufficiently for their analgesia requirement to be reduced. In eight patients, there was a significant fall in circulating immunoglobulin but no patient with Bence-Jones proteinuria had complete resolution of this biochemical abnormality. Although thrombocytopenia and neutropenia were common, only two patients required platelet transfusion and the treatment was in general extremely well tolerated. Survival following hemibody irradiation was similar to the survival reported from the use of "second-line" chemotherapy and we feel that hemibody irradiation is a more acceptable alternative for most patients.
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PMID:Hemibody irradiation in multiple myeloma. 397 37

The usefulness and optimal timing of laboratory coagulation tests before obstetric extradural analgesia are controversial. Moreover, the significance of mild coagulation abnormalities during pregnancy remains unclear. We have assessed the reliability of coagulation tests performed several weeks before delivery as predictors of coagulation abnormalities during labour. Platelet count, plasma fibrinogen concentration, prothrombin time (PT) and activated partial thromboplastin time (aPTT) were sampled in 797 women during the ninth month of pregnancy and checked during labour. Platelet count was less than 100 x 10(9) litre-1 for 11 women during labour. Only three had been detected by the first sample. Platelet count less than 100 x 10(9) litre-1 or fibrinogen concentration less than 2.9 g litre-1 during labour were associated with an increase in the incidence of postpartum haemorrhage (odds ratio = 19.7). We conclude that a platelet count several weeks before delivery was not reliable in predicting thrombocytopenia during labour and that women with mild coagulation abnormalities in early labour may need special attention regarding the risk of postpartum haemorrhage.
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PMID:Pre-anaesthetic assessment of coagulation abnormalities in obstetric patients: usefulness, timing and clinical implications. 921 19

A 46-year-old woman with antiphospholipid syndrome (APS) underwent an emergent laparotomy. The symptoms and signs of APS are reported to be thrombosis, habitual abortion, thrombocytopenia and biological false positive (BFP) for syphilis' tests. Clinical symptoms are based on hypercoagulation of blood, while prothrombin time (PT) activity and activated partial thromboplastin time (APTT) are prolonged. Although we have selected general endotracheal anesthesia without epidural catheterization, we recommend that the regional analgesia is suitable for those APS patients with abnormality of coagulation. If PT and APTT differ from clinical symptoms, we have to think about APS and manage the patients carefully as APS.
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PMID:[Anesthetic management of a patient with antiphospholipid syndrome]. 951 36

Internists are frequently asked to do preoperative consultations and to manage perioperative complications. Realistic goals are to identify patient factors that increase the risk of surgery, to quantify this risk in order to make decisions about the appropriateness of and timing of the surgery, to provide recommendations on how to minimize the risk, to identify and manage coexisting medical conditions and their associated medication requirements, to monitor the patient for perioperative problems, and to make recommendations to deal with these problems when they occur. With few exceptions, nonselective imaging and laboratory screening tests have repeatedly been shown to be of little value when the history and physical do not suggest a problem. The risk associated with the planned surgery can be estimated, with the most common serious complications being cardiac events. Updated versions of Goldman's risk indices are particularly helpful for this. Clinical variables are optimally combined with selective stress testing to discern which patients will benefit from preoperative revascularization. This has been studied best in the setting of vascular surgery. A critical guiding principle is that the value of revascularization must be judged in terms of long term gains rather than just immediate perioperative benefit. Other interventions include the selective use of beta blockers, adequate analgesia for all, control of hypertension, and appropriate volume management, especially in the settings of preexisting CHF or valvular disease. It must also be recognized that perioperative ischemia and CHF often present atypically. An approach that combines aspects of both the ACC/AHA and the ACP guidelines seems optimal. A variety of noncardiac issues must also be addressed. Postoperative pulmonary complications are common, especially with preexisting pulmonary disease, thoracic and upper abdominal surgery, and obesity. PFTs and ABGs are indicated in selected patients. Stopping smoking, incentive spirometry, and selective use of bronchodilators and antibiotics are helpful. Patients with rheumatologic diseases have specific concerns based on systemic manifestations of disease including anemia, thrombocytopenia, pulmonary fibrosis, pericarditis, and hypercoagulability; medication effects particularly from steroids and nonsteroidal anti-inflammatory drugs; and specific joint problems including contractures and atlantoaxial joint instability. Diabetes increases the risk of infection and cardiac complications. Prevention of ketoacidosis and glucose control are necessary and can be achieved through a variety of approaches, depending on whether the patient suffers from Type 1 or Type 2 diabetes. The threshold for transfusion has increased in recent years, as has the use of erythropoietin and autologous blood donation. There is no longer an absolute hemoglobin that requires transfusion, although most require transfusion for hemoglobins less than 8 mg/dL, especially in the setting of cardiac disease and bloody surgery. The elderly require surgery at an increased rate and often do not do as well as younger patients. The primary issues are, however, not their age but their increased frequency of underlying disease and diminished reserve. The latter makes them prone to postoperative delirium, sensitivity to medications, and cardiac and pulmonary problems. Despite the many diseases that patients often have and the stresses of surgery itself, modern anesthetic and surgical techniques allow almost all patients to undergo necessary procedures at acceptable risk. The internist plays a critical role in minimizing this risk even further.
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PMID:Recognition and management of preoperative risk. 1046 30

Expert and aggressive pre-operative preparation of the woman with severe pre-eclampsia will ultimately determine her intraoperative outcome. Such considerations as the effect of endotracheal manipulation on intracranial pressure, of thrombocytopenia on the potential to produce a compressive epidural haematoma following epidural or combined spinal-epidural neuraxial block and of adequacy of invasive monitoring for Caesarean section loom large in the eyes of an anaesthetist preparing such a patient for surgery. Time spent pre-operatively in fluid volume optimization, in assessment of ventricular function, filling pressures and systemic vascular resistance, on aspiration pneumonitis and seizure prophylaxis, on control of hypertension, on correction of coagulopathy and on attenuation of pressor responses is time well spent and will have profound effects on the peri-operative course. The choice of agents and techniques for control of hypertension and reduction of vascular resistance, for induction and maintenance of general anaesthesia, for eclampsia prophylaxis and for regional anaesthesia or analgesia for operative or spontaneous delivery is, likewise, important and, at times, problematic.
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PMID:Clinical management of established pre-eclampsia and gestational hypertension: an anaesthetist's perspective. 1074 95


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