During pregnancy, the procoagulant activity increases (manifested by elevation in factor VII, factor VIII, factor X, and fibrinogen levels), while the anticoagulant activity decreases (characterized by reduction in fibrinolysis and protein S activity), resulting in hypercoagulation. Standard coagulation tests, such as prothrombin time or activated partial thromboplastin time, are still used despite the lack of evidence supporting its accuracy in evaluating the coagulation status of pregnant women. Thromboelastography and rotational thromboelastometry, which are used to assess the function of platelets, soluble coagulation factors, fibrinogen, and fibrinolysis, can replace standard coagulation tests. Platelet count and function and the effect of anticoagulant treatment should be assessed to determine the risk of hematoma associated with regional anesthesia. Moreover, anesthesiologists should monitor patients for postpartum hemorrhage (PPH), and attention should be paid when performing rapid coagulation tests, transfusions, and prohemostatic pharmacotherapy. Transfusion of a high ratio of plasma and platelets to red blood cells (RBCs) showed high hemostasis success and low bleeding-related mortality rates in patients with severe trauma. However, the effects of high ratios of plasma and platelets and the ratio of plasma to RBCs and platelets to RBCs in the treatment of massive PPH were not established. Intravenous tranexamic acid should be administered immediately after the onset of postpartum bleeding. Pre-emptive treatment with fibrinogen for PPH is not effective in reducing bleeding. If fibrinogen levels of less than 2 g/L are identified, 2–4 g of fibrinogen or 5–10 ml/kg cryoprecipitate should be administered.
Anesthesia, Conduction ; Blood Coagulation Factors ; Blood Transfusion ; Drug Therapy ; Erythrocytes ; Factor VII ; Factor VIII ; Factor X ; Female ; Fibrinogen ; Fibrinolysis ; Hematoma ; Hemorrhage ; Hemostasis ; Humans ; Mortality ; Partial Thromboplastin Time ; Plasma ; Platelet Count ; Postpartum Hemorrhage ; Postpartum Period ; Pregnancy ; Pregnant Women ; Protein S ; Prothrombin Time ; Thrombelastography ; Tranexamic Acid

BACKGROUND: The purpose of this study was to find additional effects of intrathecal nalbuphine 1 mg to morphine 0.1 mg for pain relief during a cesarean section. METHODS: Sixty healthy patients at full term who were scheduled for an elective cesarean delivery with spinal anesthesia were enrolled in the study. They received 0.5% bupivacaine 10 mg with either morphine 0.1 mg (group M), or nalbuphine 1 mg (group N), or morphine 0.1 mg nalbuphine 1 mg (group M + N). Analgesic effects were evaluated by a verbal rating scale on the duration of complete analgesia (time from the intrathecal injection to the first pain report), effective analgesia (time from the intrathecal injection to the first analgesic request), and cumulative doses of additional analgesics. Hemodynamic changes and adverse effects were also observed. RESULTS: The duration of complete analgesia increased significantly in group M, compared with group N and group M + N. Effective analgesia was longer in group M and group M + N, compared with group N. The incidence of pruritus was significantly lower in group N, compared with group M and M + N. The incidence of nausea and vomiting was the same among all groups. CONCLUSIONS: We concluded that intrathecal addition of nalbuphine 1mg to morphine 0.1 mg during spinal anesthesia for a cesarean delivery reinforced intraoperaitive analgesia compared with intrathecal morphine 0.1 mg. However, it reduced the duration of complete analgesia and had no effect on the incidence of pruritus.
Analgesia ; Analgesics ; Anesthesia, Spinal ; Bupivacaine ; Cesarean Section* ; Female ; Hemodynamics ; Humans ; Incidence ; Injections, Spinal ; Morphine* ; Nalbuphine* ; Nausea ; Pregnancy ; Pruritus ; Vomiting

BACKGROUND: This study was performed to accurately discover the correlation between the epidural depth and physical measurements. METHODS: We measured the L2-3, L3-4 epidural depth pre-marked on the needle shaft only when the block was successful. Correction of the depth was made by the angulation of the needle from the perpendicular line (with regard to both the x- and y-axis) to the skin. Height and weight from the medical record was noted and neck, waist, and hip circumferences of each subject was measured. Physical parameters such as waist/neck (waist circumference-to-neck circumference ratio), waist/height (waist circumference-to-height ratio), waist/hip (waist circumference-to-hip circumference ratio), weight/neck (weight- to-neck circumference ratio), weight/height (weight-to-height ratio) and body mass index (BMI) were calculated. Peason's correlation and a regression test between the epidural depth and the physical mea surements were performed. RESULTS: Significant correlation with epidural depth was found in weight, waist, hip, neck, BMI, waist/height, waist/hip, weight/neck, and weight/height. With the regression test, we found weight to be the most important for predicting epidural depth (R square = 0.330, P < 0.05). CONCLUSIONS: Weight has the highest predictive value for lumbar epidural depth.
Body Mass Index ; Hip ; Medical Records ; Neck ; Needles ; Skin

BACKGROUND: Pneumoperitoneum and head-down tilt during a laparoscopic hysterectomy causes significant alterations in the hemodynamics including decreased cardiac output. The aim of this study was to evaluate the effects of a crystalloid preload on the hemodynamics after a hysterectomy (LAVH). METHODS: The patients were randomized to receive either no crystalloid fluid preload (control group: 29 women) or 10 ml/kg of a crystalloid fluid preload over 10 min (preloading group: 30 women) before the pneumoperitoneum. The hemodynamic parameters were measured before inducing anesthesia, immediately after the tracheal intubation, before the skin incision, and 2, 5, 10, 20, and 30 min after the pneumoperitoneum with CO2 with noninvasive cardiac output measurements using the partial CO2 rebreathing method. RESULTS: The cardiac index (CI) was reduced 2 and 5 min after the pneumoperitoneum, and then returned to normal. There were no significant differences in the CI after the pneumoperitoneum between the two groups (P<0.05). CONCLUSIONS: The administration of a 10 ml/kg crystalloid preload did not attenuate the decrease in the CI after pneumoperitoneum.
Anesthesia ; Cardiac Output ; Female ; Head-Down Tilt ; Hemodynamics* ; Humans ; Hysterectomy ; Hysterectomy, Vaginal* ; Intubation ; Pneumoperitoneum* ; Skin

BACKGROUND: The purpose of this study was to evaluate the correlations between mean blood pressure (MBP), cardiac index (CI), and systemic vascular resistance index (SVRI) in patients undergoing laparoscopically-assisted vaginal hysterectomy (LAVH). METHODS: The authors enrolled 47-female patients prior to a LAVH. Hemodynamic parameters were measured before anesthetic induction, just after tracheal intubation, before skin incision, and 2, 5, 10, 20, and 30 min after pneumoperitoneum with CO2 by noninvasive cardiac output measurement using the partial carbon dioxide rebreathing method. RESULTS: CI was significantly reduced 2 and 5 min after pneumoperitoneum (2.6 +/- 0.7 L/min/m2, and 2.5 +/- 0.7 L/min/m2, respectively), and then returned to the pre-skin incision level. SVRI increased significantly after pneumoperitoneum and was then restored to that measured pre-skin incision at 20 min after pneumoperitoneum. MBP before anesthetic induction was found to be correlated with CI at 20 and 30 min after pneumoperitoneum (R = 0.37, P = 0.022, R = 0.37, P = 0.036, respectively). A moderate correlation was observed between MBP before anesthetic induction and SVRI at 2, 5, 10, 20, and 30 min after pneumoperitoneum (R = 0.39 0.60, P < 0.05). CONCLUSIONS: MBP before anesthetic induction correlated with CI at 20, and 30 min after pneumoperitoneum and with SVRI at 2, 5, 10, 20, and 30 min after pneumoperitoneum. Howerer, reduced CI at 2, 5, and 10 min after pneumoperitoneum was not correlated with MBP before anesthetic induction.
Arterial Pressure* ; Blood Pressure ; Carbon Dioxide ; Cardiac Output ; Female ; Hemodynamics ; Humans ; Hysterectomy, Vaginal* ; Intubation ; Pneumoperitoneum ; Skin ; Vascular Resistance*

BACKGROUND: In an outcome-based health care environment, the demonstration of patient satisfaction with postoperative care has become an important criterion for quality of care assessment. The purpose of this study was to evaluate the effects of hand massage therapy and preoperative information on postoperative patient satisfaction. METHODS: One hundred full term patients scheduled for elective cesarean section under combined spinal- epidural anesthesia were randomly assigned to either the control group (n = 50) or the experimental group (n = 50). The experimental group received a hand massage and preoperative information about their surgery and anesthesia, whereas the control group did not. Twenty-four h after surgery, postoperative patient satisfaction was assessed with questionnaire consisting of 20 items in a blind manner. RESULTS: The mean postoperative satisfaction score of the experimental group was significantly higher than that of the control group (94.9 +/- 15.6 vs. 52.2 +/- 8.5). The pain score postoperatively of the experimental group was significantly lower than that of the control group (0.4 +/- 2.1 vs. 2.1 +/- 0.6), but the pain score at a postoperative 24 h and total analgesic requirement were similar in the two groups. CONCLUSIONS: Preoperative information supply and hand massage therapy are useful interventions that improve postoperative patient satisfaction.
Anesthesia* ; Anesthesia, Epidural ; Cesarean Section* ; Delivery of Health Care ; Female ; Hand* ; Humans ; Massage* ; Patient Satisfaction ; Postoperative Care ; Pregnancy ; Surveys and Questionnaires ; Relaxation

BACKGROUND: This study was conducted to compare the efficacy of a combination of ondansetron and dexamethasone with that of metoclopramide and dexamethasone for prevention of postoperative nausea and vomiting (PONV) in gynecologic patients receiving fentanyl IV-patient controlled analgesia. METHODS: One hundred patients were divided into two groups at random. In Group O, 5 mg of dexamethsone was administered after tracheal intubation, while 4 mg of ondansetron was administered at the end of surgery. In Group M, 5 mg of dexamethsone was administered after tracheal intubation and 20 mg metoclopromide was administered at the end of surgery. During the experiment, the PONV was evaluated at regular intervals. In addition, the incidence of nausea, and vomiting and the numerical rating scale (NRS) of nausea was measured (range, 0-10). RESULTS: The overall incidence of PONV in Group O was 22/50 (44%) while that in Group M was 19/50 (38%). There were no significant differences in the incidence of nausea, moderate to severe nausea (NRS of nausea, 4-10), or vomiting between groups. CONCLUSIONS: Treatment with a combination of 20 mg metoclopramide and 5 mg dexamethasone is an effective, safe, and inexpensive way to prevent PONV when compared to treatment with 4 mg ondansetron and 5 mg dexamethasone.
Analgesia ; Antiemetics ; Dexamethasone ; Fentanyl ; Humans ; Incidence ; Intubation ; Metoclopramide ; Nausea ; Ondansetron ; Postoperative Nausea and Vomiting ; Vomiting

BACKGROUND: Pneumoperitoneum and a head-down tilt during a laparoscopically-assisted vaginal hysterectomy (LAVH) decrease the cardiac index with a concurrent increase in blood pressure. This study investigated the effects of bolus nicardipine on the changes in the hemodynamics. METHODS: The patients scheduled for LAVH were randomly assigned to 1 of 3 treatment groups: control (n = 40) receiving normal saline; NIC 15 (n = 40) and NIC 30 (n = 40) groups receiving intravenous nicardipine 15 microgram/kg, 30 microgram/kg, respectively 1min before pneumoperitoneum. The hemodynamic parameters (mean blood pressure [MBP], cardiac index [CI], and heart rate [HR]) were measured before inducing anesthesia (INI, only the MBP and HR [the CI was not measured]), immediately after tracheal intubation (INT), prior to the skin incision (BF), and 2, 5, 10, 20, and 30 min after pneumoperitoneum (P2, P5, P10, P20, P30) by noninvasive cardiac output measurements. A p value < 0.05 was considered statistically significant. RESULTS: In the control group, the MBP increased significantly 5min after pneumoperitoneum compared with the INI. There was a decrease in the MBP in the NIC 30 group at P2, P5 compared with the INI, but there was no reduction of MBP at INI > 20%. In the control group, the CI had decreased at P2, P5 in comparison with BF. An increase of CI was observed at P5 in the NIC 15 group and at P2, 5, and 10 in the NIC 30 group compared with the control group. CONCLUSIONS: Intravenous bolus dosing of 30 microgram/kg nicardipine at 1 min before pneumoperitoneum during LAVH can reduce the decrease in CI after pneumoperitoneum and Trendelenburg position in LAVH but the blood pressure needs to be monitored carefully.
Anesthesia ; Blood Pressure ; Cardiac Output ; Female ; Head-Down Tilt ; Heart Rate ; Hemodynamics* ; Humans ; Hysterectomy ; Hysterectomy, Vaginal* ; Intubation ; Laparoscopy ; Nicardipine* ; Pneumoperitoneum* ; Skin

BACKGROUND: Nausea and vomiting during regional anesthesia for a cesarean section are common and unpleasant complications. This study was designed to assess the efficacy of prophylactic low dose granisetron on nausea and vomiting of patients undergoing a cesarean section with epidural anesthesia in a prospective, randomized, and double blind manner. METHODS: Sixty obstetric patients not in labor received epidural anesthesia with 20 mL of 2% lidocaine plus epinephrine (1 : 100,000) and 4 mL of diluted morphine 2 mg was administrated for postoperative pain control. Maternal hypotension was prevented aggressively by fluid administration and an ephedrine injection. The patients were assigned randomly to one of four groups to receive a placebo (normal saline) or granisetron in a dose of 10micro gram/kg, 20micro gram/kg, or 30micro gram/kg i.v. before peritoneal closure. Emetic episodes and emetic scores rating from 0 to 4 were observed during the 24 hours after surgery. RESULTS: The emetic score was statistically lower in the granisetron 30micro gram/kg group than the other groups, and was lower in the granisetron 20micro gram/kg group than the placebo and granisetron 10micro gram/kg group. Adverse events were headache, dizziness, sedation and pruritus, which were not serious. CONCLUSIONS: Prophylactic use of low dose granisetron (20-30micro gram/kg) is effective in postoperative nausea and vomiting in a cesarean section with epidural anesthesia using lidocaine and morphine when hypotension as one of the contributing factors was minimized.
Anesthesia, Conduction ; Anesthesia, Epidural* ; Antiemetics ; Cesarean Section* ; Dizziness ; Ephedrine ; Epinephrine ; Female ; Granisetron* ; Headache ; Humans ; Hypotension ; Lidocaine ; Morphine ; Nausea ; Pain, Postoperative ; Postoperative Nausea and Vomiting ; Pregnancy ; Prospective Studies ; Pruritus ; Vomiting*

BACKGROUND: Patients anesthetized by extension of epidural analgesia during labor frequently experience intraoperative visceral pain during cesarean section. Visceral pain is known to be related to anxiety. We evaluated pain and preoperative anxiety using the numeric rating scale (NRS-11), and examined the relationship of anxiety with failure of extension of epidural analgesia due to intraoperative pain. METHODS: Patients received continuous epidural infusion at a rate of 10 ml/h for labor pain. Two percent lidocaine mixed with 100 microg fentanyl, 1:200,000 epinephrine, and 2 mEq bicarbonate was injected through the epidural catheter for cesarean section. Failure of epidural anesthesia was defined as the need for conversion to general anesthesia or supplementation with opioids, sedatives, or inhalants after epidural anesthesia for cesarean section. We investigated the relationship of preoperative factors including preoperative anxiety with failure of epidural anesthesia. RESULTS: Heavier weight of parturients, more cervical dilatation at the time of epidural analgesia administration, higher pain NRS score after epidural analgesia, higher pain NRS score before epidural analgesia for cesarean section, and lower rate of iv pethidine due to shivering were associated with a higher failure rate of epidural anesthesia. The failure rate of epidural anesthesia was comparable between the high anxiety group (NRS > 4) and the low anxiety group (NRS < or = 4). CONCLUSIONS: Preoperative anxiety evaluated by NRS may not be associated with failure of extension of epidural analgesia due to visceral pain during intrapartum cesarean section.
Analgesia, Epidural* ; Analgesics, Opioid ; Anesthesia, Epidural ; Anesthesia, General ; Anxiety* ; Catheters ; Cesarean Section* ; Epinephrine ; Female ; Fentanyl ; Humans ; Hypnotics and Sedatives ; Labor Pain ; Labor Stage, First ; Lidocaine ; Meperidine ; Pregnancy ; Shivering ; Visceral Pain