The incidence and neonatal effects of maternal hypotension during epidural anesthesia for cesarean section.
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Biomedical subjects
Publications and source records attributed to G Levinson.
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Previous reports have interpreted hybridization between snake satellite DNA and DNA clones from a variety of distant taxonomic groups as evidence for evolutionary conservation, which implies common ancestry (homology) and/or convergence (analogy) to produce the cross-hybridizing sequences. We have isolated 11 clones from a genomic library of Drosophila melanogaster, using a cloned 2.5-kb snake satellite probe of known nucleotide sequence. We have also analysed published sequence data from snakes, mice, and Drosophila. These data show that (1) all of the cross-hybridization between the snake, fly, and mouse clones can be accounted for by the presence of either of two tandem repeats, [GATA]n and [GACA]n and (2) these tandem repeats are organized differently among the different species. We find no evidence that these sequences are homologous apart from the existence of the simple repeat itself, although their divergence from a common ancestral sequence cannot be ruled out. The sequences contain a variety of homogeneous clusters of tandem repeats of CATA, GA, TA, and CA, as well as GATA and GACA. We suggest that these motifs may have arisen by a self-accelerating process involving slipped-strand mispairing of DNA. Homogeneity of the clusters might simply be the result of a rate of accumulation of tandem repeats that exceeds that of other mutations.
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The effects of placental transfer of enflurane and halothane were studied in 81 women undergoing cesarean sections. All patients had rapid sequence induction using thiopental, succinylcholine, and endotracheal intubation. They were then randomly assigned to one of five groups: Group I (n = 16) received N2O and oxygen, Group II (n = 16) N2O, oxygen, and 0.25% halothane, Group III (n = 18) N2O, oxygen, and 0.5% halothane, Group IV (n = 18) N2O, oxygen, and 0.5% enflurane, Group V (n = 13) N2O, oxygen, and 1% enflurane. At delivery, blood was drawn from the maternal artery, umbilical vein and artery for measurement of the halogenated agents using gas chromatography. The neonates were evaluated by Apgar scores, umbilical artery and vein acid base status and the Early Neonatal Neurobehavioral Scores (ENNS) at 2 and 24 h of age. Blood loss and the incidence of maternal awareness were also determined. The umbilical vein to maternal vein ratio was approximately 0.5 and 0.6 for enflurane and halothane, respectively. The umbilical artery to umbilical vein ratio was 0.5 with both agents; higher inspired anesthetic concentrations produced higher blood levels. All neonates had Apgar scores of 8 or more at 5 min with the exception of one neonate in the N2O group. Maternal and neonatal acid base status, blood loss, and ENNS were not affected by the addition of the halogenated agents. Of the patients who had N2O alone, 12% had awareness versus none in the other groups. These data demonstrate that low dose halothane or enflurane decreases the incidence of maternal awareness and does not adversely affect the neonate.
Awake, unanesthetized, and paralyzed sheep made hypoxic and acidotic were given equivalent low and high intravenous doses of lidocaine and bupivacaine over 10 sec. Within 30 sec of injections, all animals had electroencephalographic evidence of convulsions. After administration of low-dose lidocaine, arrhythmias associated with significant hemodynamic changes did not occur; after administration of high-dose lidocaine, half of the animals became hypotensive but had no arrhythmias other than sinus tachycardia. However, after administration of low-dose bupivacaine, all sheep had evidence of serious electrocardiographic changes or arrhythmias, and one animal died. After administration of high-dose bupivacaine, serious electrocardiographic changes occurred in all animals, and despite resuscitative efforts, all died. The most common abnormality after bupivacaine administration was a wide-QRS-complex bradycardia, occurring in most animals regardless of dose. Two-thirds of the animals given high-dose bupivacaine had electromechanical dissociation and subsequent refractory asystole. Although the mechanism of action is not known, bupivacaine appears to be more cardiotoxic than lidocaine. This toxicity is enhanced in animals by the presence of hypercarbia, acidosis, and hypoxia.
We have used the enzyme elastase to remove the basal lamina of epithelia from two insects: the upper Malpighian tubules of Rhodnius prolixus and imaginal discs of Drosophila melanogaster. Removal of the basal lamina was confirmed using scanning and transmission electron microscopy. Use of the technique on the Malphighian tubules of Rhodnius reveals for the first time the three-dimensional organization of the circumferential folds of the basal plasma membrane. Elastase is much more effective in removing the basal lamina than are the enzymes hyaluronidase, collagenase, and chymotrypsin, either alone or in combination. Following elastase treatment, cells of the Malpighian tubules dissociate with only mild mechanical agitation into single, viable cells. Treatment with elastase removes the basal laminae of imaginal discs of Drosophila and accelerates evagination as has been previously described for trypsin. To obtain single cell preparations from elastase-treated imaginal discs, mechanical stirring in Ringer low in Ca2+ was required. In addition to its usefulness in cell isolation, elastase treatment allows examination of the effect of removal of basal laminae on the physiology and development of insect epithelia.
Controversy persists about the cardiac toxicity of bupivacaine if accidentally administered intravenously during regional anesthesia. Using awake, unanesthetized sheep, we evaluated the cardiac effects of low and high equivalent doses of lidocaine and bupivacaine given intravenously over 10 s. All animals convulsed within 30 s of injections. Although both drugs significantly increased heart rate and systemic and pulmonary arterial blood pressure for up to 10 min, cardiac output was affected variably. The magnitude of hemodynamic changes that each drug produced did not differ significantly from each other at either dose level. However, of the sheep receiving intravenous lidocaine, none developed arrhythmias other than mild sinus tachycardia and minimal ST-T wave changes (which occurred in 25% of the animals). After intravenous bupivacaine injection, all sheep had transient changes on the EKG and/or arrhythmias (e.g., supraventricular tachycardia; atrioventricular condition blocks; ventricular tachycardia; multiform premature ventricular contractions; wide QRS complexes; ST-T wave changes; and in one animal, fatal ventricular fibrillation). Normal sinus rhythm usually returned within 8-10 min. Arterial blood gas and acid-base values stayed within the normal range during the studies, and serum potassium did not change significantly from control. In conclusion, in conscious adult sheep, equivalent doses of lidocaine or bupivacaine produced similar central nervous system (CNS) toxicity when rapidly injected intravenously. In the absence of marked hypoxia, respiratory or metabolic acidosis, hyperkalemia, or hypotension, serious cardiac arrhythmias occurred after bupivacaine but not lidocaine.
We studied 33 women scheduled to undergo general anesthesia for cesarean section. Prior to induction of anesthesia, each patient received in a random fashion one of two prophylactic antacids. Group I (n = 17) received 30 ml Gelusil orally and Group II (n = 16) received 30 ml of 0.3 mol/l sodium citrate. After induction of general anesthesia an oro-gastric tube was passed. The amount and pH of the gastric aspirate were measured at the time of delivery and 45 min after delivery "before extubation." Both antacids elevated gastric pH above 3.5 in all patients but one in the Gelusil group. The pH remained elevated 45 min later. It is concluded that 0.3 mol/l sodium citrate is effective as an antacid when given orally prior to induction of anesthesia.
To determine whether epidural anesthesia during labor affects maternal circulating catecholamines, blood samples were obtained from 15 patients at the peak of and immediately after two consecutive painful contractions. A lumbar epidural local anesthetic without epinephrine was then administered. After the onset of analgesia, four blood samples were again drawn. All samples were analyzed by a radioenzymatic assay for epinephrine and norepinephrine concentrations. Before anesthesia, the mean (+/-SEM) plasma epinephrine level was 280 +/- 49 pg/ml, and the mean norepinephrine level was 866 +/- 122 pg/ml. After anesthesia, epinephrine levels decreased 56% (p less than 0.01). Although norepinephrine levels decreased approximately 19%, this reduction was not statistically significant. At the height of a contraction, catecholamine levels did not differ significantly from those occurring between contractions. Lumbar epidural anesthesia during labor reduces maternal epinephrine levels, probably by eliminating the psychological and physical stress associated with painful uterine contractions or by denervating the adrenal medulla. Whatever the mechanism, reducing pain and activity of the sympathetic nervous system should increase uterine blood flow.
A variety of examinations are currently available for evaluating the neurobehavior of the newborn. These exams are often difficult and time-consuming to perform, require extensive training of the examiners, and produce results that may be difficult to interpret. The authors describe a new Neurologic and Adaptive Capacity Score (NACS) for full-term neonates and compare it with the Scanlon Early Neonatal Neurobehavioral Scale (ENNS), the most widely used test for evaluating effects of obstetric medication on the neonate. The NACS was designed as a screening test to detect central nervous system depression from drugs and also to differentiate these effects from those found after birth trauma and perinatal asphyxia. The NACS is based on 20 criteria, each of which is given a score of 0, 1, or 2. These criteria assess five general areas: 1) adaptive capacity; 2) passive tone; 3) active tone; 4) primary reflexes; and 5) alertness, crying, and motor activity (general observations). In contrast to the ENNS, the NACS places more emphasis on motor tone, avoids the use of noxious stimuli (pinprick, repeated Moro examinations), takes half the time to perform, and provides for any given baby a single number that immediately identifies a depressed or vigorous neonate.
The authors studied the neonatal neurobehavioral effects of nitrous oxide:oxygen and enflurane:oxygen inhalation analgesia for vaginal delivery. Parturients were assigned randomly to receive no inhalation agent (Group 1, n = 21); enflurane, 0.3 to 0.8 per cent, and oxygen (Group 2, n = 22); or nitrous oxide, 30 to 50 per cent, and oxygen (Group 3, n = 18). Infants were tested at 15 min, 2 h, and 24 h of age using the Neurologic and Adaptive Capacity Score (NACS); and at 2 and 24 h using the Early Neonatal Neurobehavioral Scale (ENNS). No significant differences in neurobehavioral status occurred. For all groups, scores tended to be lowest at two hours of age. We conclude that neither enflurane nor nitrous oxide analgesia adversely affects neonatal neurobehavioral status at 15 min, 2 h, or 24 h of age.
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The effects of enflurane analgesia (approximately 0.5%) were studied in 55 patients during the second stage of normal vaginal delivery and were compared with effects of nitrous oxide (approximately 40%) in 50 similar patients. The enflurane and oxygen mixture was rated satisfactory by 89% of the mothers and 80% of the anesthesiologists. These ratings did not differ significantly from those for nitrous oxide. Obstetricians, however, rated the enflurane and oxygen mixture superior. The newborns of mothers receiving both agents wee vigorous and comparable when assessed by Apgar scores and cord blood gas tensions. The estimate of blood loss was similar in both groups. Serum inorganic fluoride concentrations in the mother after anesthesia were not significantly increased from preanesthetic levels with either agent. There was no biochemical evidence of renal toxicity. In neonates of mothers given enflurane, the mean umbilical cord concentration of serum inorganic fluoride ions was 2.4 +/- 0.2 micromoles/L, a value well below that associated with nephrotoxicity.
The long, slender cones of the teleost retina elongate at night and contract during the day. In the Midas cichlid, Cichlasoma citrinellum, this cone excursion is elicited both by changes in light conditions and by strong endogenous circadian rhythms. In a normal day/night cycle. C. citrinellum cones change length by 69 micron. We have found that in this species an endogenous circadian rhythm induces substantial cone excursion in contrast light as well as in constant darkness. Total excursion in constant light is 34% of that seen in a normal cycle. Total excursion in constant darkness is 58% of that seen in a normal cycle. Similar excursions are observed on the second and third days of constant darkness. A change from light to darkness at a time in the cycle other than dusk induces elongation averaging 49% of the total excursion observed in the normal cycle. A change from darkness to light at a time other than dawn induces cone contraction averaging 30% of the total excursion observed in the normal cycle. The response of retinal cones to either of the above changes in light conditions is a relatively constant magnitude at all sampling times over a 24 hr period. We conclude that both the endogenous circadian rhythm and the responses to changes in light conditions of the cones and required to produces the full excursion observed in the normal day/night cycle. Full elongation of cones can occur only at night in darkness, and full contraction of the cones can occur only in the day in the light. Changing light conditions at inappropriate times produces intermediate cone lengths.
Ephedrine is the most popular vasopressor used in obstetrics to prevent or treat spinal or epidural hypotension. Fetal heart rate (FHR) changes during epidural anesthesia were studied in 71 patients; it was found that ephedrine administration (57 patients) was associated with significant increases in FHR and beat-to-beat variability. These changes were dose related and were not associated with fetal asphyxia as judged by measurement of fetal scalp blood pH or Apgar scores.
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