Oxytocin in parturients with cardiac disease.
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Cesarean Section↗
Biomedical subjects
G O'Sullivan
Publications and source records attributed to G O'Sullivan.
C1-esterase inhibitor deficiency and elective caesarean section.
C1-esterase inhibitor deficiency is a rare disorder of the complement system characterised by episodes of cutaneous and mucosal oedema. Life-threatening airway oedema can follow airway instrumentation or minor trauma. We describe the successful management of a 37-year-old primiparous woman with inherited C1-esterase inhibitor deficiency who was admitted at 38 weeks' gestation for elective caesarean section. Whilst undergoing general anaesthesia 18 months previously she had experienced facial and pharyngeal oedema despite prophylaxis (one unit of fresh frozen plasma). On this occasion she underwent elective caesarean section following intrathecal anaesthesia with 0.5% hyperbaric bupivacaine 2 mL and diamorphine 300 microg. Cardiovascular stability was ensured using glycopyrolate and intravenous Hartmann's solution 2 L; a live female infant was delivered successfully. There were no peri- or postoperative complications. Regional anaesthesia is the safest method for providing surgical anaesthesia in the obstetric patient. We believe elective caesarean section under regional anaesthesia should be considered if there are predicted difficulties with vaginal delivery.
Adult↗
Assessing bupivacaine 10 mg/fentanyl 20 microg as an intrathecal test dose.
After ethics committee approval and verbal consent, women undergoing elective caesarean section given spinal anaesthesia with hyperbaric 0.5% bupivacaine 10 mg (2 mL) plus fentanyl 20 microg (spinal group, n = 20) and women requesting epidural analgesia in labour given the same drugs and doses epidurally, either in the same concentration (epidural small volume group, n = 10) or as 10 mL of 0.1% bupivacaine plus fentanyl 20 microg (epidural large volume group, n = 12) were recruited. The temperature of the great toes, sensory block on the outer ankle (S1 dermatome), motor block at the ankle and haemodynamic changes were recorded every 2 min for 10 min. There was a significant rise in foot temperature only in the spinal group. At four minutes a combination of warm toes and motor or sensory block, usually both, were seen only in the spinal groups. Haemodynamic changes were non-specific. We conclude that bupivacaine 10 mg with fentanyl 20 microg is a reliable agent to detect intrathecal placement by 4 min by which time a combination of motor and sensory block at the ankle and toe warming should be present.
Journal Article↗
A randomised controlled trial of fluid pre-loading before low dose epidural analgesia for labour.
Preloading with fluid is recommended before regional block in labour. Low dose epidurals may produce less haemodynamic disturbance than traditional stronger solutions of local anaesthetics. Our aim was to compare the incidence of hypotension in normal labouring women who received a low dose epidural (0.1% bupivacaine 15 mL with fentanyl 2 microg microg.mL(-1)) with and without an i.v. crystalloid preload. Women with normal labours were randomised to the intervention group: no i.v. crystalloid preload (n = 85) and the control group: 7 mL mL.kg(-1) i.v. crystalloid solution before epidural injection (n = 83). Mean arterial pressure was recorded every 5 min for 30 min. There was no difference between the groups in mean decrease in mean arterial pressure and similar proportions of women showed falls in mean arterial pressure of 20% or greater (13% vs. 11%, risk ratio 1.2, 95% CI 0.54 to 2.8, P = 0.6). Blinded analysis by independent obstetricians revealed no differences in the fetal heart rate abnormalities (20% vs. 15%, risk ratio 1.3, 95% CI 0.67 to 2.7). A scientifically valid conclusion whether preloading is useful cannot be drawn from this study. This study suggests that about 350 participants in each group would be necessary to exclude a type 2 error in a future study.
Clinical Trial↗
Home treatment as an alternative to inpatient admission: characteristics of those treated and factors predicting hospitalization.
In response to the NHS Plan, crisis and home treatment teams will be developed across the UK in order to provide intensive home treatment as an alternative to inpatient admission for individuals with severe, acute mental health problems. This study describes aspects of the work of two teams in Hertfordshire. A total of 293 individuals were taken on for intensive home treatment in a 12-month period. A range of social and demographic variables was recorded at the point of initial assessment regarding each individual, as well as two rating scales: the Brief Psychiatric Rating Scale and the Scale for Suicide Ideation. Sixty-two individuals (21.1%) required admission to hospital after a median period of home treatment of 11 days. The most frequently recorded reason for admission taking place was 'risk to self' (n = 33, 53.2%). Two variables were identified by logistic regression analysis as being predictive of an increased risk of hospitalization: high suicidal ideation at initial assessment (P < 0.01) and previous hospital admission (P < 0.01). Although statistically significant, these variables were only weakly predictive of whether admission would actually take place.
Adolescent↗
Validation of the Welch Allyn 'Vital Signs' blood pressure measurement device in pregnancy and pre-eclampsia.
OBJECTIVE: To establish the accuracy the Welch Allyn 'Vital Signs' blood pressure monitor in pregnancy and pre-eclampsia according to a modified British Hypertension Society protocol. DESIGN: Prospective observational study. SETTING: Maternity Unit/Obstetric Ward, Guy's and St Thomas' Hospital, London, UK. POPULATION: Forty-three pregnant women of whom 12 had pre-eclampsia. METHODS: Nine sequential same-arm measurements were taken from each woman by two trained observers, alternating between a mercury sphygmomanometer and the device. The last seven readings were analysed according to the British Hypertension Society protocol. The accuracy of the device was determined using the grading scale indicated by the British Hypertension Society protocol (grade A/B = pass, grade C/D = fail). MAIN OUTCOME MEASURES: Grading criteria of the British Hypertension Society Protocol. RESULTS: The Welch Allyn 'Vital Signs' monitor achieved a grade A for both systolic and diastolic pressures in pregnant women who did not have pre-eclampsia. In those women with pre-eclampsia, it achieved a grade D and B for systolic and diastolic pressures, respectively. The mean differences between the observers and the device in women without pre-eclampsia were -2.6 (6.4) and -1.5 (7.2) mmHg for systolic and diastolic pressures [and in pre-eclamptic women -7.8 (6.3) and -5.5 (6.5)mmHg]. It therefore fulfils criteria set by the Association for the Advancement of Medical Instrumentation (mean <5 mmHg and standard deviation <8 mmHg) in pregnancy, but not in pre-eclampsia. CONCLUSION: This is the first automated device suitable for robust clinical use that can be recommended for use in pregnancy. However, it should be borne in mind that-similar to other devices--it significantly under--recorded readings obtained in pre-eclamptic women.
Blood Pressure↗
Labour--a gastronomic experience!
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Editorial↗
Probiotic impact on microbial flora, inflammation and tumour development in IL-10 knockout mice.
BACKGROUND: The enteric bacterial flora has been implicated in the pathogenesis of enterocolitis and colon cancer in C57BL/6 IL-10 knockout mice. Probiotic Lactobacilli modify the enteric flora and are thought to have a beneficial effect on enterocolitis. We conducted a controlled feeding trial in IL-10 knockout mice using the probiotic Lactobacillus salivarius ssp. salivarius UCC118. AIM: To determine the effect of probiotic consumption on the gastrointestinal microflora, tumour development and colitis in IL-10 knockout mice. METHODS: Twenty IL-10 knockout mice were studied (10 consumed probiotic organisms in milk and 10 consumed unmodified milk) for 16 weeks. Faecal microbial analysis was performed weekly to enumerate excretion of the probiotic UCC118, total lactobacilli, Clostridium perfringens, bacteroides, coliforms, bifidobacteria and enterococci. At sacrifice, the small and large bowel were microbiologically and histologically assessed. RESULTS: L. salivarius UCC118 was detected in faeces from all mice in the probiotic fed group, but not the control group. Faecal coliform and enterococci levels were significantly reduced in probiotic fed animals compared to the controls (P < 0.05). At sacrifice, a significant reduction in C. perfringens numbers was observed in the test mice (P < 0.05). There were no fatalities in the test group compared to two deaths from fulminant colitis in the control group. Only one test mouse developed colonic adenocarcinoma compared to five in the control group. Test animal mucosal inflammation consistently scored lower than that of the control mice. CONCLUSION: In this placebo controlled trial, modification of enteric flora in IL-10 knockout mice by probiotic lactobacilli was associated with reduced prevalence of colon cancer and mucosal inflammatory activity.
Animals↗
Effect of lateral versus supine wedged position on development of spinal blockade and hypotension.
Aortocaval compression may not be completely prevented by the supine wedged or tilted positions. It is commonly believed, however, that the unmodified full lateral position after induction of spinal anaesthesia might allow excessive spread of the block. We therefore compared baseline arterial pressures in the supine wedged, sitting, tilted and full lateral positions in 40 women who were about to undergo elective caesarean section. They were then given spinal anaesthesia in the left lateral position and randomised to be turned to the right lateral or the supine wedged position, after which speed of onset and spread of blockade to cold sensation were measured every 2 min for 10 min and mean arterial pressure and ephedrine requirement were recorded every minute for 20 min. Baseline mean arterial pressure was 9 mmHg (95% CI 3 to 14) lower in the left lateral (measured in the upper arm) than in the sitting position; those in the supine wedged and tilted positions were intermediate. Following spinal anaesthesia, hypotension (defined as a reading </=80% of the baseline value in the same position) lasted 2.4 min longer (CI +0.6 to +4.1) in the supine wedged group, but there was no significant difference between the groups in maximum fall or ephedrine requirement. The upper level of block rose more rapidly in the supine wedged than in the lateral group and showed less variability. There is therefore no reason to fear the unmodified lateral group position, which may offer better protection against hypotension.
Clinical Trial↗
Subdural haematoma after dural puncture headache treated by epidural blood patch.
Subdural haematoma is a well-documented complication of accidental dural puncture, and is thought to be preventable by prompt treatment with an epidural blood patch. An accidental dural puncture occurred in a 39-yr-old primagravida during the siting of an epidural catheter for pain relief in labour. Twenty hours after the puncture, the mother developed a typical postdural puncture headache, which increased in severity over the subsequent 24 h. An epidural blood patch was performed at 48 h, and this initially relieved the headache. After discharge from hospital, and 14 days after the dural puncture, the headache recurred, together with expressive dysphasia, poor co-ordination and sensory loss in the right arm. A magnetic resonance imaging scan demonstrated a left sided subdural haematoma, which was drained successfully with complete recovery.
Adult↗
True lateral dermoid cyst of the floor of the mouth.
Congenital dermoid cysts of the floor of the mouth are relatively rare but when they occur, they do so inevitably in the midline. We present a case of a true lateral dermoid cyst of this region without any intra-oral extension. We discuss the anatomical and histological classification of dermoid cysts within the floor of the mouth.
Adult↗
Delivery of nasal drops to the middle meatus: which is the best head position?
BACKGROUND: Chronic sinusitis and intranasal polyps require long-term topical drug therapy. The issue of drug delivery to the critical area of the middle meatus is rarely addressed. AIM: The aim of this study was to compare the delivery of drops to the middle meatus using four different head positions (Mecca, Mygind, Ragan and Head back). The study also assessed the discomfort with each position whilst administering the nasal drops. METHODS: Nine nostrils in five healthy volunteers were studied to compare the delivery of drops to the middle meatus using the four different head positions. A neurosurgical patty was placed under direct vision in the middle meatus using a rigid nasendoscope. Six drops of dyed-saline were administered into each nostril. Upon removal, a quantitative assessment was made of the amount of dye absorbed and discomfort assessed. The direction of flow of the nasal drops in the nose was also demonstrated. RESULTS: The 'Mygind' and 'Ragan' positions were superior to the 'Mecca' and 'Head back' positions in delivery of drops to the middle meatus. The 'Mecca' position was the most uncomfortable. CONCLUSION: We recommend that the 'Mygind' or 'Ragan' position should be used for nasal drop administration.
Cross-Over Studies↗
Pars tensa retraction pockets in children: treatment by excision and ventilation tube insertion.
Tympanic membrane retraction pockets involving the pars tensa are not uncommon in clinical practice. Recurrent infections, ossicular erosion and cholesteatoma are the recognized sequelae. The management options include surveillance, medical treatment and surgery. The surgical procedures range from grommet insertion to extensive tympanoplasty procedures. We report our experience with simple excision and grommet insertion, performed in 31 ears in 26 patients as day cases. The follow-up ranged from 8 to 34 months with a mean of 16 months. The procedure was successful in 23 ears (success rate of 74%). Recurrence of retraction occurred in seven ears and in one ear there was a persistent perforation. Age, previous grommet insertion and severity of retraction did not have a statistically significant influence on the final outcome. We conclude that excision and grommet insertion is a simple, safe and efficient procedure for the management of tympanic membrane retraction pockets and can be considered in preference to extensive tympanoplasty.
Adolescent↗
Paraesthesiae and nerve damage following combined spinal epidural and spinal anaesthesia: a pilot survey.
Concern has been expressed that recent changes in techniques of spinal blockade may have resulted in an increase in frequency of neurological sequelae. In order to make preliminary enquiries about anaesthetists' recent experiences of neurological sequelae following spinal and combined spinal-epidural anaesthesia, a questionnaire, covering numbers of procedures, needles used and any neurological problems that had been encountered, was sent to the anaesthetist in charge of each obstetric centre on the Royal College of Obstetricians and Gynaecologists' United Kingdom list. Replies were received from 222 of the 259 units, of whom 40 reported a total of 56 cases involving prolonged neurological sequelae, of which nine were probable obstetric palsies, 18 could be attributed to the regional procedure (one instance of conus damage and the rest largely sensory disturbances) and 29 were of uncertain origin, including a second conus damage. There was no obvious difference in incidence of problems associated with combined spinal-epidural vs. the single-shot spinal technique (odds ratio 1.14, confidence interval 0.53 to 2.46), or Sprotte vs. Whitacre atraumatic needle (odds ratio 1.40, confidence interval 0.64 to 3.08). A prospective survey, or better still, randomisation would be needed to verify these findings.
Journal Article↗
Surgical management of intractable epistaxis: audit of results.
We have audited our results after changing the management practice in patients with intractable epistaxis. These patients are offered trans-nasal endoscopic sphenopalatine artery diathermy with or without anterior ethmoid artery diathermy instead of conventional surgical procedures. During the first year after the change in practice, 145 patients were treated as inpatients for epistaxis. Ten patients (seven per cent) required a surgical procedure under general anaesthesia due to the recurrent nature of bleeding. All 10 patients had endoscopic sphenopalatine artery diathermy, whereas in four patients anterior ethmoid artery diathermy was also performed concurrently. The post-operative hospital stay ranged from one to three days (mean 2.1 days). The mean follow-up was 10 months. The epistaxis recurred in one patient and this was managed conservatively. There were no complications related to surgery. In the previous year, 132 patients were admitted for epistaxis and eight patients had surgical procedures, which included septoplasty, nasal packing and external carotid artery ligation. The post-operative stay ranged from three to six days (mean 3.9 days). Our audit shows that endoscopic sphenopalatine artery diathermy is a safe, successful and effective management option for patients with refractory epistaxis. The morbidity is reduced and the hospital stay is shortened. The sphenopalatine artery diathermy can be combined with anterior ethmoid surgery, when necessary.
Aged↗
An unusual case of stridor due to osteophytes of the cervical spine: (Forestier's disease).
Stridor is a noisy breathing caused by compromised airway in the larynx and trachea. The causes can either be due to intrinsic or extrinsic compression. Stridor resulting from extrinsic compression due to anterior cervical osteophytes is rare. We report an unusual case of acute stridor due to an osteophytic mass in the cervical vertebrae resulting in a mechanical upper airway obstruction. The underlying pathology was Forestier's disease or diffuse idiopathic skeletal hyperostosis (DISH). Stridor is a rare manifestation of DISH and it certainly represents the most life-threatening one. Only a few cases have been reported in the English literature and are mainly secondary to impaired function of the vocal folds, or postcricoid ulceration and oedema. We present such a case, in that stridor was the result of direct airway obstruction by the osteophytic mass and an emergency tracheostomy had to be performed to establish an airway.
Aged↗
Eating in labour. A randomised controlled trial assessing the risks and benefits.
The aim of this study was to determine whether permitting women in labour to eat a light diet would: (i) alter their metabolic profile, (ii) influence the outcome of labour, and (iii) increase residual gastric volume and consequent risk of pulmonary aspiration. Women were randomised to receive either a light diet (eating group, n = 48) or water only (starved group, n = 46) during labour. The light diet prevented the rise in plasma beta-hydroxybutyrate (p = 2.3 x 10(-5)) and nonesterified fatty acids (p = 9.3 x 10(-7)) seen in the starved group. Plasma glucose (p = 0.003) and insulin (p = 0.017) rose in the eating group but there was no difference in plasma lactate (p = 0.167) between the groups. There were no differences between the groups with respect to duration of first or second stage of labour, oxytocin requirements, mode of delivery, Apgar scores or umbilical artery and venous blood samples. Relative gastric volumes estimated by ultrasound measurement of gastric antral cross-sectional area were larger (p = 0.001) in the eating group. This was supported by the observation that those from this group who vomited, vomited significantly larger volumes than those in the starved group (p = 0.001). We conclude that eating in labour prevents the development of ketosis but significantly increases residual gastric volume.
3-Hydroxybutyric Acid↗
Lumbar puncture and headache. "Atraumatic needle" is a better term than "blunt needle".
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Headache↗