Prevention of hypotension and prolongation of postoperative analgesia in emergency cesarean sections: A randomized study with intrathecal clonidine A randomized study of maternal serum cytokine levels following cesarean section under general or neuraxial anesthesia. Intraoperative conditions and quality of postoperative analgesia after adding dexmedetomidine to epidural bupivacaine and fentanyl in elective cesarean section using combined spinal-epidural anesthesia Subhypnotic Doses of Propofol Do not Relieve Pruritus Induced by Intrathecal Morphine After Cesarean Section Early Compared With Late Neuraxial Analgesia in Nulliparous Labor Induction: A Randomized Controlled Trial Intrathecal injection of magnesium sulfate: shivering prevention during cesarean section: a randomized, double-blinded, controlled study Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition) A study of low-dose S-ketamine infusion as "preventive" pain treatment for cesarean section with spinal anesthesia: benefits and side effects. Intravenous Oxytocin in Patients Undergoing Elective Cesarean Section Comparison of Intrathecal Dexmedetomidine with Morphine as Adjuvants in Cesarean Sections. The Effect of Neuraxial Versus General Anesthesia Techniques on Postoperative Quality of Recovery and Analgesia After Abdominal Hysterectomy: A Prospective, Randomized, Controlled Trial Effect of preoperative warming during cesarean section under spinal anesthesia Intrathecal Meperidine Plus Lidocaine for Prevention of Shivering during Cesarean Section Incidence of shivering after cesarean section under spinal anesthesia with or without intrathecal sufentanil: a randomized study. Intrathecal fentanyl for prevention of shivering in cesarean section. Intrathecal fentanyl for prevention of shivering in spinal anesthesia in cesarean section Effect of low dose of intrathecal pethidine on the incidence and intensity of shivering during cesarean section under spinal anesthesia: a randomized, placebo-controlled, double-blind clinical trial The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. Incidence of neuraxial haematoma after total hip or knee surgery: RECORD programme (rivaroxaban vs. enoxaparin) Neuraxial block versus general anaesthesia for cesarean section: post-operative pain scores and analgesic requirements. Intraoperative forced air-warming during cesarean delivery under spinal anesthesia does not prevent maternal hypothermia. Effects of intrathecal dexmedetomidine on shivering after spinal anesthesia for cesarean section: a double-blind randomized clinical trial Bilateral multi-injection iliohypogastric-ilioinguinal nerve block in conjunction with neuraxial morphine is superior to neuraxial morphine alone for postcesarean analgesia. Effects of preoperative sublingual misoprostol on uterine tone during isoflurane anesthesia for cesarean section. Neuraxial block, death and serious cardiovascular morbidity in the POISE trial. The effects of timing of prophylaxis, type of anesthesia, and use of mechanical methods on outcome in major orthopedic surgery – subgroup analyses from 17,701 patients in the XAMOS study The Safety and Efficacy of Extended Thromboprophylaxis With Fondaparinux After Major Orthopedic Surgery of the Lower Limb With or Without a Neuraxial or Deep Peripheral Nerve Catheter: The EXPERT Study
Background and Context : Different adjuvants been tried out for neuraxial anesthesia in emergency caesarean section so that the dose of the local anesthetic can be reduced and hypotension thereby prevented . Aims and Objectives : The present study was carried out in patients presenting for emergency lower segment caesarean section ( LSCS ) to establish the dose of intrathecal clonidine that would allow reduction of the dose of local anesthetic ( thereby reducing the incidence and magnitude of hypotension ) while at the same time providing clinical ly relevant prolongation of spinal anesthesia without significant side effects . Material s and Methods : This r and omized clinical study was carried out in our institution among 100 pregnant females who underwent emergency caesarean section .  The participants were divided r and omly into four groups : A , B , C , and D , each comprising 25 parturients . Subarachnoid block was performed using a 26 G Quincke needle , with 12 mg of hyperbaric bupivacaine ( LA ) in group A , 9 mg of LA + 30 μg of clonidine in group B , LA + 37.5 μg of clonidine in group C , and LA + 45 μg of clonidine in group D. The solution was uniformly made up to 2.2 mL with normal saline in all the groups . Onset of analgesia at T10 level , sensory and motor blockade levels , maternal heart rate and blood pressure , neonatal Apgar scores , postoperative block characteristics , and adverse events were looked for and recorded . Statistical analysis was carried out with SPSS ® version 10.0 for Windows ® , using the ANOVA test with post hoc significance , the Chi-square test , and the Mann-Whitney U test . P<.05 was considered significant and P<.0001 as highly significant . Results : One hundred patients were enrolled for this study . The four groups were comparable with regard to demographic data and neonatal Apgar scores . Onset and establishment of sensory and motor analgesia was significantly shorter in groups C and D , while hypotension ( and the use of vasopressors ) was significantly higher in groups A and D. Perioperative shivering , nausea , and vomiting were significantly higher in groups A and D , while incidence of dry mouth was significantly higher in group D. Conclusions : The addition of 45 μg , 37.5 μg , and 30 μg of clonidine to hyperbaric bupivacaine results in more prolonged complete and effective analgesia , allowing reduction of up to 18 % of the total dose of hyperbaric bupivacaine . From the results of this study , 37.5 μg of clonidine seems to be the optimal dose BACKGROUND Cytokines are significant mediators of the immune response to surgery and also play a role in parturition . The aim of the study was to investigate the impact of the anesthetic technique for cesarean section on plasma levels of cytokines IL-6 and TNF-alpha . METHODS Thirty-five parturients scheduled for elective cesarean section were r and omly assigned to  general ( n=18 ) or neuraxial ( n=17 ) anesthesia . The general anesthesia group received thiopental 4 mg/kg , succinylcholine 1 - 1.5 mg/kg and 1 % end-tidal concentration of sevoflurane in nitrous oxide and 50 % oxygen . The neuraxial anesthesia group received intrathecal 0.5 % levobupivacaine 1.8 - 2.2 mL and epidural fentanyl 1 microg/kg . Blood sample s were taken for IL-6 and TNF-alpha immediately after positioning the parturient on the operating table , after uterine incision and before the umbilical cord clamping and 24h after surgery ( T(1 ) , T(2 ) and T(3 ) respectively ) . RESULTS The two groups did not differ in IL-6 ( P=0.15 ) or TNF-alpha ( P=0.73 ) serum concentrations at any time point . In the general and neuraxial anesthesia groups , IL-6 serum concentrations were significantly higher in the third blood sample , T(3 ) ( 12.2+/-5.0 and 15.2+/-4.3 pg/mL ) , than in T(1 ) ( 0.41+/-0.38 and 0.29+/-0.10 pg/mL ) and T(2 ) ( 0.37+/-0.47 and 0.24+/-0.05 ) respectively ( P<0.001 ) . Within each group , serum TNF-alpha concentrations did not differ significantly over time ( P=0.44 ) . CONCLUSIONS Under the present study design anesthetic technique did not affect IL-6 or TNF-alpha concentrations in parturients undergoing elective cesarean section . Serum IL-6 levels increased 24 h postoperatively independently of anesthetic technique This study was design ed to evaluate the effect of adding dexmedetomidine to regular mixture of epidural drugs for pregnant women undergoing elective cesarean section with special emphasis on their sedative properties , ability to improve quality of intraoperative , postoperative analgesia , and neonatal outcome . Material s and Methods : Fifty women of ASA physical status I or II at term pregnancy were enrolled r and omly to receive plain bupivacaine plus fentanyl ( BF Group ) or plain bupivacaine plus mixture of fentanyl and dexmedetomidine ( DBF Group ) . Incidence of hypotension , bradycardia , Apgar scores , intraoperative pain assessment , onset of postoperative pain , sedation scores , and side effects were recorded . Results : No difference in the times taken for block to reach T4 sensory level , to reach the highest level of sensory block , and interval between first neuraxial injection and onset of surgery between the groups was noted . Onset of postoperative pain was significantly delayed in the DBF group ( P = 0.001 ) , the need for supplementary fentanyl was significantly less in DBF group ( P = 0.03 ) , no significant difference was noted between both groups regarding neonatal Apgar scores as well as the incidence of hypotension , bradycardia , nausea , vomiting , and duration of motor blockade . DBF group had significantly less incidence of shivering ( P = 0.03 ) . Conclusion : Adding dexmedetomidine to regular mixture of epidural anesthetics in women undergoing elective cesarean section improved intraoperative conditions and quality of postoperative analgesia without maternal or neonatal significant side effects The purpose of this study was to determine whether subhypnotic doses of propofol effectively relieve pruritus in women who received intrathecal morphine for postoperative analgesia after cesarean delivery . Twenty-nine women who developed pruritus after undergoing an elective cesarean section and receiving intrathecal morphine ( 0.25 mg ) for postoperative analgesia were enrolled in this r and omized , prospect i ve , double-blind study . The women were r and omly assigned to receive either 1 mL of propofol ( n=17 ) or 1 mL of placebo ( n=12 ) IV . Pruritus was evaluated 5 min after treatment . In the absence of successful treatment , the women received another 1 mL of the same drug . Pruritus was again evaluated 5 min after the second dose . We found that pruritus was successfully treated twice in the propofol group and once in the placebo group ( P = not significant ) . The antipruritic action of propofol lasted for up to 6 h in one woman and 15 min in the other . The one success in the placebo group lasted for 15 min . We conclude that the success rate of propofol in treating  pruritus in women who received intrathecal morphine for postoperative analgesia after cesarean delivery is not significantly different from that of placebo . Implication s : Pruritus is a common and bothersome side effect of neuraxial opioids after cesarean section . Subhypnotic doses of IV propofol ( 10 mg ) have been used to treat pruritus caused by neuraxial opioids . In this prospect i ve , r and omized , double-blind study , we found that propofol does not relieve pruritus in women who underwent cesarean section and received intrathecal morphine sulfate ( 0.25 mg ) for postoperative pain relief . ( Anesth Analg 1998;86:310 - 3 OBJECTIVE : To determine whether early initiation of neuraxial analgesia ( anesthetic[s ] placed around the nerves of the central nervous system ) compared with systemic opioid analgesia , followed later in labor by epidural analgesia , increases the rate of cesarean delivery in nulliparas undergoing induction of labor . METHODS : Nulliparas undergoing induction of labor who requested analgesia when cervical dilation was less than 4 cm participated in the study . Patients were r and omized to neuraxial ( early ) or systemic opioid ( late ) analgesia at the first analgesia request . Patient-controlled epidural analgesia was initiated in the early group at the second analgesia request and in the late group at cervical dilation of 4 cm or greater or at the third analgesia request . The primary outcome was the rate of cesarean delivery . RESULTS : The rate of cesarean delivery was not different between groups ( neuraxial [ early ] 32.7 % compared with systemic [ late ] 31.5 % , 95 % confidence interval of the difference -3 % to 6 % , P=.65 ) . A sample size of 30,500 would be required to detect a difference at the observed rate . There were no differences in the mode of vaginal delivery or Apgar scores . Pain scores were significantly lower ( median 1 compared with 5 on a 0–10 scale , P<.001 ) and labor duration shorter ( median 528 minutes compared with 569 minutes , P=.047 ) in the early group . The incidence of reassuring fetal heart rate tracings after analgesia was not different between groups . CONCLUSION : Early-labor neuraxial analgesia does not increase the cesarean delivery rate compared with late epidural analgesia in nulliparas undergoing induction of labor . CLINICAL TRIAL REGISTRATION : Clinical Trials.gov , www . clinical trials.gov , NCT00380978 LEVEL OF EVIDENCE : Background Regional anesthesia is known to significantly impair thermoregulation and predispose patients to hypothermia . We hypothesized that the addition of an intrathecal injection of magnesium sulfate ( MgSO4 ) to bupivacaine would improve perioperative shivering in female patients undergoing elective caesarean section . Methods In a block-r and omized , double-blinded , controlled trial 72 patients scheduled for elective caesarean section with spinal anesthesia were separated into two groups . In the treatment group , 2 ml of 0.5 % bupivacaine plus 25 mg MgSO4 ( 0.5 ml ) were injected intrathecally , and in the control group 2 ml of 0.5 % bupivacaine plus 0.5 ml normal saline were injected intrathecally . Core temperature was measured before and after drug injection at predetermined intervals . Sedation was grade d using the Ramsay sedation scale . Results No significant intergroup differences in appearance of shivering were seen immediately or at 5 , 30 , 40 , 50 , 60 , and 90 min after block administration . However , at 10 , 15 , and 20 min post block , there was a significant difference in shivering . The group administered MgSO4 showed lower shivering grade s compared with the control group . Core temperature was significantly reduced in the MgSO4 group compared to the normal saline group 30 min after blocking . Conclusions Intrathecal injection of MgSO4 improved perioperative shivering in female patients undergoing elective caesarean section The actual incidence of neurologic dysfunction result ing from hemorrhagic complications associated with neuraxial blockade is unknown . Although the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics , recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient population s. Overall , the risk of clinical ly significant bleeding increase with age , associated abnormalities of the spinal cord or vertebral column , the presence of an underlying coagulopathy , difficulty during needle placement , and an indwelling neuraxial catheter during sustained anticoagulation ( particularly with st and ard heparin or low-molecular weight heparin ) . The need for prompt diagnosis and intervention to optimize is also consistently reported . In response to these patient safety issues , the American Society of Regional Anesthesia and Pain Medicine ( ASRA ) convened its Third Consensus Conference on Regional Anesthesia and Anticoagulation . Practice guidelines or recommendations summarize evidence -based review s. However , the rarity of spinal hematoma defies a prospect i ve r and omized study , and there is no current laboratory model . As a result , the ASRA consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation . These are based on case reports , clinical series , pharmacology , hematology , and risk factors for surgical bleeding . An underst and ing of the complexity of this issue is essential to patient management BACKGROUND Attenuation of central sensitization with NMDA-active drugs such as S-Ketamine may play a role in postoperative analgesia and prevention of neuropathic pain . However , during cesarean section with neuraxial block , S-Ketamine might have adverse effects on the interaction between mothers and infants , including breastfeeding . METHODS Women undergoing elective repeat cesarean section with subarachnoid anesthesia ( 0.5 % hyperbaric bupivacaine 8 - 10 mg and sufentanil 5 μg ) were enrolled in a double-blind , r and omized study . Patients in the S-Ketamine group ( N.=28 ) received i.v . midazolam 0.02 mg/kg and S-Ketamine 0.5 mg/kg i.m . bolus 10 minutes after birth followed by a 2 μg/kg/min i.v . continuous infusion for 12 h. The  control group ( N.=28 )  received placebo . Paracetamol and patient controlled analgesia with intravenous morphine were given postoperatively . Von Frey filaments were used to assess pain threshold on the inner forearm and T10-T11 dermatomes ( supposed hyperalgesic area ) . RESULTS S-Ketamine  reduced morphine consumption at 4 - 8 , 8 - 12 , and 12 - 24 hours after surgery ( total 31 % ) , even after its effect has ceased , suggesting an anti-hyperalgesic action . Mild side effects were observed in the S-Ketamine group one hour after delivery . All side effects were rated as light and there were no serious adverse events . Pain threshold was not significantly different between groups . S-Ketamine patients showed a trend towards reduced pain sensitivity at the T10 dermatome , which is involved by surgical damage . After three years , patients reported no differences in residual pain , dysesthetic symptoms , or duration of breast-feeding . CONCLUSION Preventive administration of S-Ketamine via 12-hour infusion was safe and may have anti-hyperalgesic action after cesarean section The objective of this study was to compare four different doses of oxytocin to determine its minimal effective dose during elective cesarean section . A prospect i ve , double-blind , r and omized study was undertaken in 40 healthy term parturients presenting for elective cesarean section under regional anesthesia . Subjects were assigned to one of four groups . Group I received 5 IU , Group II 10 IU , Group III 15 IU , and Group IV 20 IU of oxytocin after clamping of the umbilical cord .  Uterine tone was assessed by palpation on a linear analog scale ( LAS ) of 0 to 10 ( 0 = completely atonic , 10 = fully contracted ) at 5 , 10 , 15 and 20 min after the start of oxytocin infusion . Estimated blood loss ( EBL ) and the difference in pre- and postoperative hematocrit ( Delta Hct ) were also recorded . At alpha = 0.05 , the study design had a power of 95 % to detect a 25 % difference in the LAS between the four groups . There were no differences in the uterine tone in the four groups at any of the four intervals . EBL and Delta Hct were similar in all four groups . There appears to be no benefit in terms of degree of uterine contraction and amount of blood loss to administering more than 5 IU of intravenous oxytocin to term parturients undergoing elective cesarean section with a neuraxial block . ( Anesth Analg 1997;84:753 - 6 To compare the effects of intrathecal dexmedetomidine and intrathecal morphine as supplements to bupivacaine in cesarean sections under spinal anesthesia . Full-term parturients ( n=120 ) undergoing elective cesarean sections under spinal anesthesia were r and omly allocated into three groups : Group B received 10 mg bupivacaine , Group BD received 10 mg bupivacaine plus 5 µg dexmedetomidine , and Group BM received 10 mg bupivacaine plus 100 µg morphine .  The onset and regression time of sensory and motor blockade , postoperative analgesia , and side effects were recorded . Group BD showed quicker onset time and a longer sensory and motor blockade than other groups ( BD vs. B and BD vs. BM , p<0.05 ) . The mean time of sensory regression to the S1 segment was 253.21±42.79 min in group BD , 192.50±40.62 min in group BM and 188.33±37.62 min in group B ( p<0.001 ) . Group BD showed an analgesia duration ( time to requirement of first rescue analgesic ) ( 17.59±6.23 h ) similar to that of group BM ( 16.78±5.90 h ) but longer than that of group B ( 3.53±1.68 h ) ( p<0.001 ) . The incidence of pruritus was significantly higher in group BM compared with groups BD and B ( p<0.001 ) . Less shivering was observed in group BD than in groups BM and B ( p=0.009 ) . So intrathecal dexmedetomidine ( 5 µg ) prolonged the motor and sensory blockade , provided a similar analgesic effect and reduced pruritus and shivering compared with morphine ( 100 µg ) in cesarean sections BACKGROUND : Patients undergoing abdominal hysterectomy often have significant postoperative pain despite the use of concurrent multimodal pain strategies . Neuraxial anesthesia has opioid-sparing effects and may provide better postoperative recovery to patients when compared with general anesthesia . Our main objective in this study was to compare the effects of neuraxial and general anesthesia on postoperative quality of recovery after abdominal hysterectomy . METHODS : The study was a prospect i ve , r and omized , controlled clinical trial . Seventy healthy females were recruited and r and omized to a general anesthesia or neuraxial technique  as their primary anesthetic regimen . The primary outcome was the global quality of recovery—40 question naire ( QoR–40 ) at 24 hours after the surgical procedure . Other data collected included postoperative pain scores and opioid consumption . Data were analyzed using the Mann – Whitney U test , Fisher 's exact test , and linear regression . A P value < 0.05 was considered statistically significant . RESULTS : The median difference ( 95 % confidence interval [ CI ] ) in the global QoR–40 score at 24 hours between the neuraxial and general anesthesia groups was 17 ( 11 to 21.5 ) ( P < 0.001 ) . Patients in the neuraxial anesthesia group had better quality of recovery scores in all the QoR–40 subcomponents than did the general anesthesia group ( all P < 0.005 ) . The median difference in global QoR–40 scores at 48 hours between the neuraxial anesthesia and the general anesthesia groups was 8 ( 6–10 ) ( P < 0.001 ) . Postoperative opioid consumption and pain scores were higher in the general anesthesia group than in the neuraxial anesthesia group . There was an inverse linear relationship between opioid consumption and postoperative quality of recovery at 24 hours , r 2 = 0.67 ( P < 0.0001 , 95 % CI of 0.77 to 0.51 ) , and at 48 hours , r 2 = 0.58 ( P < 0.0001 , 95 % CI of 0.72 to 0.42 ) . CONCLUSION : Neuraxial anesthesia provides better quality of recovery than does general anesthesia for patients undergoing abdominal hysterectomy . The opioid-sparing effects of neuraxial anesthesia were associated with a better quality of recovery in patients after the surgical procedure . In the absence of contraindications , neuraxial anesthesia seems to be a better anesthetic plan for those patients Background Postoperative hypothermia and shivering is a frequent event in patients during cesarean section under spinal anesthesia . We assessed the effect of preoperative warming during cesarean delivery under spinal anesthesia for prevention of hypothermia and shivering . Methods Forty five patients undergoing elective cesarean section were r and omly assigned to three groups . Group F received warmed intravenous fluid ( 40 ℃ ) . Group A patients were actively warmed by forced air-warming . Group C was the control group . Forced air-warming and warmed fluid was maintained for the 15 min preceding spinal anesthesia  . Core temperature ( tympanic membrane ) and the skin temperature of arm and thigh were measured and shivering was grade d simultaneously . Results The core temperature at 45 min decreased less in Groups F and A than Group C ( -0.5 ℃ ± 0.3 ℃ vs -0.6 ℃ ± 0.4 ℃ vs -0.9 ℃ ± 0.4 ℃ , respectively ; P = 0.004 ) . The arm temperature at 15 min and 30 min exhibited a greater increase in Group A than Group F and Group C ( P = 0.001 and P = 0.012 , respectively ) . Leg temperature increased similarly among the three groups . The incidence of shivering was significantly less in Group A and Group F than Group C ( 20 % , 13.3 % , and 53.3 % , respectively ; P = 0.035 ) . Conclusions Preoperative forced air-warming and warmed fluid prevents hypothermia and shivering in patients undergoing elective cesarean delivery with spinal anesthesia Background Shivering related to spinal anesthesia may interfere with monitoring and is uncomfortable . The aim of the present study was to investigate low-dose intrathecal meperidine for the prevention of shivering after induction of spinal anesthesia in parturients with cesarean section . Methods This was a prospect i ve r and omized , double-blind , placebo-controlled trial including 100 parturients , of American Society of Anesthesiologists ( ASA ) physical status I or II , scheduled for elective cesarean section under spinal anesthesia who were r and omly assigned to a meperidine ( 0.2 mg/kg ) plus hyperbaric lidocaine ( 5 % , 75 mg , n = 50 ; group M ) group or a placebo plus hyperbaric lidocaine ( 5 % , 75 mg , n = 50 ; group L ) group . Demographic and surgical data , adverse events , and the mean intensity for each parturient were assessed during the entire study period by a blinded observer . Results There were no significant differences between the two study groups regarding the demographic and surgical data ( P > 0.05 ) . The incidence of shivering during the entire study period significantly decreased in the group of parturients who received intrathecal meperidine ( P = 0.04 ) . There were no significant differences in nausea and vomiting between the two groups . Conclusions Low-dose intrathecal meperidine ( 10 mg ) is safe and effective in reducing the incidence and severity of shivering associated with spinal anesthesia in parturients with cesarean section BACKGROUND AND OBJECTIVES Shivering is a cause of discomfort and dissatisfaction in patients undergoing cesarean section . The objective of this study paper was to assess the impact of intrathecal administration of sufentanil on the incidence of shivering after cesarean section . METHOD In a prospect i ve blinded , r and omized clinical trial , pregnant women undergoing cesarean section under spinal anesthesia were enrolled . Pregnant women in labor , febrile , obese , with pregnancy-induced hypertension , anesthetic block failure or surgical complications were excluded . Patients were r and omly assigned to two groups . In Group I , 10 mg of 0.5 % hyperbaric bupivacaine combined with 80 mcg of morphine and 2.5 mcg of sufentanil were administered . In Group II , 10 mg of 0.5 % hyperbaric bupivacaine combined with 80 mcg of morphine were administered . In the post-anesthesia care unit , patients were evaluated for signs of shivering by an investigator blinded to the patient 's group allocation . RESULTS The sample consisted of 80 patients . In both groups there was a decrease in axillary temperature of patients after cesarean section ( p<0.001 ) . This decrease was not different between groups ( p<0.21 ) . In Group I , the incidence of tremor was 32.5 % ( 13/40 ) and in Group II it was 62.5 % ( 25/40 ) ( p<0.007 ) ; RR 0.53 ( CI 95 % 0.32 - 0.87 ) . CONCLUSIONS It has been suggested that the addition of sufentanil to hyperbaric bupivacaine and morphine during spinal anesthesia for cesarean section provides a decrease in the incidence of shivering in the immediate postoperative period OBJECTIVES The aim of this r and omized double-blind study was to investigate whether 20 microg of intrathecally administered fentanyl would influence the incidence and severity of shivering in patients undergoing cesarean section . MATERIAL AND METHOD Sixty healthy patients scheduled for cesarean section under spinal anesthesia using 2.2 ml of 0.5 % hyperbaric bupivacaine with 0.2 ml of morphine 0.2 mg , were r and omly allocated to receive an additional 0.4 ml of fentanyl 20 mg intrathecally ( Group F ) or normal saline 0.4 ml ( Group S ) . RESULTS The incidence of shivering three hours after spinal anesthesia was 6 of 30 patients , 20 % in Group F and 15 of 30 patients , 50 % in Group S. The difference was statistically significant ( p < 0.05 ) . Almost all of the shivering patients started in their first hour after spinal anesthesia ( 5 patients in Group F and 13 patients in Group S ) . None in Group F but 4 patients in Group S started shivering before their babies were delivered . The shivering score was also significantly lower in Group F ( p < 0.05 ) . Treatment for shivering was requested in 16 % and 26 % of the shivering patients in Group F and Group S , respectively . There was no difference in the incidence of pharmacologic side effects . The core temperature did not differ significantly between the groups during 3 hours after spinal anesthesia . CONCLUSION The addition of 20 microg fentanyl in 2.2 ml of 0.5 % hyperbaric bupivacaine with 0.2 ml of morphine 0.2 mg intrathecally can reduce the incidence and severity of intraoperative and postoperative shivering after spinal anesthesia for patients who were receiving cesarean section without increasing other side effects Background Shivering is one of the common problems in spinal anesthesia . The objective of the present study was to evaluate the effect of intrathecal fentanyl ( 25 µg ) on incidence and severity of intraoperative and postoperative shivering . Methods A double-blind r and omized controlled study was conducted in eighty healthy women ( ASA Physical status I ) scheduled for elective cesarean section under spinal anesthesia . Subjects were r and omly divided into two equal groups . The patients received 12.5 mg ( 2.5ml ) of 0.5 % hyperbaric bupivacaine combined with 25 µg ( 0.5 ml ) fentanyl in Group F as a study group and 12.5 mg ( 2.5ml ) of 0.5 % hyperbaric bupivacaine combined with 0.5 ml normal saline in Group S as a control group . Incidence of shivering during 30 and 60 minutes of surgery and recovery and complications were evaluated . Results The total incidence of shivering in Group F was significantly lower than Group S ( 10 % in group F ; 75 % in group S , p < 0.0001 ) . Almost all patients started shivering in the first hour after spinal anesthesia and the rate of shivering especially in second 30 minutes was higher than first 30 minutes in both groups . None in Group F but 22 patients ( 55 % ) in Group S had shivering during recovery and all of them reported shivering at the first 30 minute at recovery . The severity of shivering in Group F was significantly lower than Group S ( p < 0.0001 ) . Conclusion Intrathecal bupivacaine combined with fentanyl is associated with a lower incidence and severity of shivering Introduction Shivering is among the unpleasant and potentially harmful side effects of spinal anesthesia . The aim of this r and omized double-blind clinical trial was to compare the antishivering effect of two different doses of intrathecal pethidine on the incidence and intensity of shivering and other side effects in patients who underwent cesarean section . Methods In this study , 150 parturient females scheduled for nonemergent cesarean section were r and omly allocated to three groups . Spinal anesthesia was performed with 0.5 % hyperbaric bupivacaine ( 12.5 mg ) , plus 0.5 mL of 0.9 % saline in the st and ard group ( S group ) , and the same dose of bupivacaine with 5 mg ( P5 group ) or 10 mg of pethidine ( P10 group ) . Demographic and surgical data , incidence and intensity of shivering ( primary outcome ) , hemodynamic indices , forehead and core temperatures , maximum sensory level , Apgar scores , and adverse events were evaluated by a blinded observer . Results There were no significant differences between the three study groups regarding the demographic and surgical data , hemodynamic indices , core temperatures , and maximum sensory level ( P>0.05 ) . The incidence and intensity of shivering were significantly less in the P5 and P10 groups ( P<0.001 ) when compared with the S group . There were no significant differences between groups for secondary outcomes , except pruritus , which was more common in the P5 and P10 groups when compared with the S group ( P=0.01 ) . Conclusion Low dose of intrathecal pethidine is safe , and can decrease the incidence and intensity of shivering during cesarean section , without having major side effects BACKGROUND Epidural analgesia initiated early in labor ( when the cervix is less than 4.0 cm dilated ) has been associated with an increased risk of cesarean delivery . It is unclear , however , whether this increase in risk is due to the analgesia or is attributable to other factors . METHODS We conducted a r and omized trial of 750 nulliparous women at term who were in spontaneous labor or had spontaneous rupture of the membranes and who had a cervical dilatation of less than 4.0 cm . Women were r and omly assigned to receive intrathecal fentanyl or systemic hydromorphone at the first request for analgesia . Epidural analgesia was initiated in the intrathecal group at the second request for analgesia and in the systemic group at a cervical dilatation of 4.0 cm or greater or at the third request for analgesia . The primary outcome was the rate of cesarean delivery . RESULTS The rate of cesarean delivery was not significantly different between the groups ( 17.8 percent after intrathecal analgesia vs. 20.7 percent after systemic analgesia ; 95 percent confidence interval for the difference , -9.0 to 3.0 percentage points ; P=0.31 ) . The median time from the initiation of analgesia to complete dilatation was significantly shorter after intrathecal analgesia than after systemic analgesia ( 295 minutes vs. 385 minutes , P<0.001 ) , as was the time to vaginal delivery ( 398 minutes vs. 479 minutes , P<0.001 ) . Pain scores after the first intervention were significantly lower after intrathecal analgesia than after systemic analgesia ( 2 vs. 6 on a 0-to-10 scale , P<0.001 ) . The incidence of one-minute Apgar scores below 7 was significantly higher after systemic analgesia ( 24.0 percent vs. 16.7 percent , P=0.01 ) . CONCLUSIONS Neuraxial analgesia in early labor did not increase the rate of cesarean delivery , and it provided better analgesia and result ed in a shorter duration of labor than systemic analgesia Patients receiving anticoagulants could be at higher risk of compressive haematoma with neuraxial anaesthesia use . The phase III RECORD programme compared rivaroxaban with enoxaparin for prevention of venous thromboembolism after total hip or knee replacement surgery in more than 12,500 patients . This observational analysis evaluated the risk of neuraxial haematoma after neuraxial anaesthesia in patients receiving rivaroxaban or enoxaparin  using pooled RECORD1–4 data OBJECTIVE To evaluate the suitability of spinal and general anaesthesia for cesarean section . METHODS The prospect i ve , double-blinded study , done between March and December 2009 , at Central Education and Research Hospital , Erzurum , Turkey , involved 60 patients undergoing elective cesarean surgery .  They were grouped according to the kind of anaesthesia , with each group having 30 patients each . Postoperative pain scores , opioid requirement , side effects and patient satisfaction were compared through statistical analysis using SPSS version 10 . RESULTS Patient demographics were similar in both groups . Patients in the general anaesthesia group consumed 638.4 + /- 179.10 microg fentanyl , while patients in the spinal anaesthesia group consumed 356.3 + /- 87.1 microg . The number of patients requiring opioid via Patient Controlled Analgesia in the first 24 hours was significantly higher in the general anaesthesia group . Patient satisfaction was significantly higher in the spinal anaesthesia group . CONCLUSION Type of anaesthesia for elective cesarean section is important to provide sufficient post-operative analgesia and patient satisfaction BACKGROUND Prewarming and intraoperative warming with forced air-warming systems prevent perioperative hypothermia and shivering in patients undergoing elective cesarean delivery with epidural anesthesia . We tested the hypothesis that intraoperative lower body forced air-warming prevents hypothermia in patients undergoing elective cesarean delivery with spinal anesthesia . METHODS Thirty healthy patients undergoing cesarean delivery with spinal anesthesia were r and omly assigned to forced air-warming or control groups ( identical cover applied with forced air-warming unit switched off ) . A blinded investigator assessed oral temperature , shivering , and thermal comfort scores at 15-min intervals until discharge from the postanesthetic care unit . Umbilical cord blood gases and Apgar scores were also measured after delivery . RESULTS The maximum core temperature changes were similar in the two groups ( -1.3 degrees C + /- 0.4 degrees C vs -1.3 degrees C + /- 0.3 degrees C for the forced air-warming group and control group , respectively ; P = 0.8 ) . Core hypothermia ( < or = 35.5 degrees C ) occurred in 8 of 15 patients receiving forced air-warming and in 10 of 15 unwarmed patients ( P = 0.5 ) . The incidence and severity of shivering did not significantly differ between groups . Umbilical cord blood gases and Apgar scores were similar in both groups ( P = NS ) . CONCLUSIONS We conclude that intraoperative lower body forced air-warming does not prevent intraoperative hypothermia or shivering in women undergoing elective cesarean delivery with spinal anesthesia Background Shivering is among the common troublesome complications of spinal anesthesia ( SA ) , and causes discomfort and discontentment in parturients undergoing cesarean sections ( CSs ) . The aim of this study was to investigate the effects of intrathecal dexmedetomidine in the prevention of shivering in those who underwent CS under SA . Subjects and methods Fifty parturients planned for elective CSs under SA were enrolled in this prospect i ve , double-blinded , controlled study and r and omly divided into two equal groups . Spinal block was achieved with 12.5 mg 0.5 % heavy bupivacaine plus 5 μg dexmedetomidine ( BD group ) or 0.5 mL 0.9 % normal saline ( BN group ) . The incidence and intensity of shivering , peripheral and core body temperature , hemodynamic parameters , and adverse events was recorded . Results The incidence of shivering was significantly higher in the BN group ( 52 % ) than the BD group ( 24 % ) ( P=0.04 ) . Likewise , the intensity of shivering was significantly higher in the BN group than the BD group ( P=0.04 ) . The incidence of adverse events , such as hypotension , nausea/vomiting , and bradycardia , was not significantly different between the two groups , although the grade of sedation was higher in the BD group than the BN group ( P=0.004 ) . Conclusion We conclude that intrathecal dexmedetomidine is effective in lowering the incidence and intensity of shivering in parturients undergoing CSs under SA without major adverse effects STUDY OBJECTIVE To determine whether bilateral iliohypogastric and ilioinguinal ( IHII ) peripheral nerve blocks , given in conjunction with neuraxial morphine , reduce postcesarean analgesic requirements and side effects , result ing in improved maternal satisfaction . DESIGN R and omized , prospect i ve , double-blinded , placebo-controlled study . SETTING Labor and delivery suite at Johns Hopkins Hospital . PATIENTS 34 women scheduled for elective cesarean delivery . INTERVENTIONS Patients were r and omized to receive IHII nerve blocks bilaterally , with either total 24 mL of 0.5 % bupivacaine or normal saline , following cesarean delivery via Pfannensteil incision with a st and ard intrathecal dose of 12 mg of 0.75 % bupivacaine with 10 µg of fentanyl and 200 µg of preservative-free morphine . MEASUREMENTS Patients were assessed at 0 , 6 , 12 , 18 , and 24 hours postoperatively . Visual analog scale ( VAS ) pain scores at rest were recorded at each time period . Analgesic use , patients ' perception of nausea , vomiting , pruritus , and their overall satisfaction with their analgesia were recorded for the first 24 hours . MAIN RESULTS Lower VAS pain scores were seen in the bupivacaine group at 6 , 12 , 18 , and 24 hours postoperatively ( P = 0.01 , P < 0.01 , 0.02 , and 0.04 , respectively ) . A longer mean time to first rescue dose of ketorolac was noted in the bupivacaine group ( 14.3 ± 1.8 hrs ) than the saline group ( mean 5.6 ±1.1 hrs ) , ( P < 0.01 ) . Fewer patients in the bupivacaine group made requests for acetaminophen 500 mg/oxycodone 5 mg in the first 24 hours . Satisfaction was greater in the bupivacaine group . No difference in side effects was noted between groups . CONCLUSIONS Bilateral multilevel injection IHII nerve blocks result in lower resting VAS pain scores , lower analgesic requirements , and greater satisfaction following cesarean delivery in patients who received neuraxial morphine BACKGROUND AND OBJECTIVES Misoprostol would reduce the uterine bleeding after cesarean delivery without harmful effects on either mother or baby . We aim ed to evaluate the effects of preoperative misoprostol on maternal blood loss , uterine tone , and the need for additional oxytocin  after cesarean delivery under isoflurane anesthesia . METHODS After ethical approval , 366 patients scheduled for elective cesarean delivery were r and omly allocated to receive either sublingual misoprostol 400μg ( n=179 ) or placebo tablet ( n=187 ) after intubation . Anesthesia was maintained with 0.5 - 0.7 MAC isoflurane with nitrous oxide . All patients received intravenous infusion of 10IU of oxytocin after placental delivery . Perioperative estimated blood loss , uterine tone , need for supplementary oxytocin , hematocrit , Apgar scores at 1 and 5 min and adverse effects were recorded . RESULTS After induction , patients receiving sublingual misoprostol had significant less perioperative estimated blood loss ( 202±383.1 vs. 708±204.3mL , p<0.001 ) , need for oxytocin ( p<0.001 ) , higher hematocrit levels ( p<0.001 ) and uterine tone ( p<0.02 ) . The incidence of shivering was higher in the misoprostol group ( p=0.04 ) . There were no differences between the two groups as regarding Apgar scores , nausea and vomiting , gastrointestinal disturbances and pyrexia . CONCLUSION Preoperative administration of sublingual misoprostol 400μg is safe and effective in attenuating the maternal bleeding and uterine atony from isoflurane anesthesia for cesarean delivery BACKGROUND This post hoc analysis aim ed to determine whether neuraxial block was associated with a composite of cardiovascular death , non-fatal myocardial infa rct ion ( MI ) and non-fatal cardiac arrest within 30 days of r and omization in POISE trial patients . METHODS A total of 8351 non-cardiac surgical patients at high risk of cardiovascular complications were r and omized  to β-blocker or placebo . Neuraxial block was defined as spinal , lumbar or thoracic epidural anaesthesia . Logistic regression , with weighting using estimated propensity scores , was used to determine the association between neuraxial block and primary and secondary outcomes . RESULTS Neuraxial block was associated with an increased risk of the primary outcome [ 287 ( 7.3 % ) vs 229 ( 5.7 % ) ; odds ratio ( OR ) , 1.24 ; 95 % confidence interval ( CI ) , 1.02 - 1.49 ; P=0.03 ] and MI [ 230 ( 5.9 % ) vs 177 ( 4.4 % ) ; OR , 1.32 ; 95 % CI , 1.07 - 1.64 ; P=0.009 ] but not stroke [ 23 ( 0.6 % ) vs 32 ( 0.8 % ) ; OR , 0.76 ; 95 % CI , 0.44 - 1.33 ; P=0.34 ] , death [ 96 ( 2.5 % ) vs 111 ( 2.8 % ) ; OR , 0.87 ; 95 % CI , 0.65 - 1.17 ; P=0.37 ] or clinical ly significant hypotension [ 522 ( 13.4 % ) vs 484 ( 12.1 % ) ; OR , 1.13 ; 95 % CI , 0.99 - 1.30 ; P=0.08 ] . Thoracic epidural with general anaesthesia was associated with a worse primary outcome than general anaesthesia alone [ 86 ( 12.1 % ) vs 119 ( 5.4 % ) ; OR , 2.95 ; 95 % CI , 2.00 - 4.35 ; P<0.001 ] . CONCLUSIONS In patients at high risk of cardiovascular morbidity , neuraxial block was associated with an increased risk of adverse cardiovascular outcomes , which could be causal or because of residual confounding Purpose Real-world data on the use of rivaroxaban in the perioperative period in patients undergoing major orthopedic surgery are limited . Subsets of data from the Phase IV , non-interventional XAMOS study were analyzed to explore the potential influence of timing of the first thrombo prophylactic dose , type of anesthesia , and concomitant mechanical prophylaxis on clinical outcomes in patients undergoing major orthopedic surgery in routine clinical practice . Patients and methods In XAMOS , 8,778 patients received rivaroxaban ( 10 mg once daily ) and 8,635 received st and ard-of-care ( SOC ) pharmacological prophylaxis  ( safety population ) . Crude incidences of symptomatic thromboembolic and treatment-emergent bleeding events were analyzed according to timing of the first postoperative thromboprophylactic dose , use of general or neuraxial anesthesia , and use of mechanical prophylaxis with pharmacological thromboprophylaxis . Results In the rivaroxaban group , the incidences of symptomatic thromboembolic events were 0.7 % , 1.0 % , and 0.7 % in patients receiving the first thromboprophylactic dose at ≤6 hours , > 6 hours to ≤10 hours , and > 10 hours to ≤24 hours after surgery , respectively . In the SOC group , the incidence of symptomatic thromboembolic events was slightly higher when the postoperative dose was given at > 10 hours to ≤24 hours ( 1.8 % vs 1.1 % at ≤6 hours and 1.3 % at > 6 hours to ≤10 hours ) . The antithrombotic effect of rivaroxaban was maintained in comparison to the SOC group . The incidence of major bleeding ( RECORD trial definition ) was low and similar between the two treatment groups and was not influenced by timing of the first thromboprophylactic dose . Neuraxial anesthesia was used more than any other form of anesthesia for both hip and knee surgery ; the effectiveness of rivaroxaban was not influenced by the type of anesthesia used . No spinal hematomas were reported in patients receiving neuraxial anesthesia in either treatment group . Use of mechanical thromboprophylaxis in addition to rivaroxaban or SOC pharmacological prophylaxis did not reduce the risk of thromboembolic events further . Conclusion The effectiveness and safety of rivaroxaban in patients undergoing major orthopedic surgery in routine clinical practice were maintained irrespective of timing of the first postoperative dose within 24 hours after surgery , the type of anesthesia , and the additional use of mechanical thromboprophylaxis BACKGROUND : The benefit-risk ratio of extended fondaparinux therapy has not been assessed in patients undergoing major lower limb joint arthroplasty . Few data on the concomitant use of fondaparinux and continuous neuraxial or deep peripheral nerve blockade are available . We performed a prospect i ve intervention study in patients undergoing major orthopedic surgery primarily design ed to assess the efficacy of fondaparinux when drug administration was withheld for 48 h to permit removal of a neuraxial or deep peripheral nerve catheter . The safety and efficacy of extended fondaparinux therapy for the prevention of venous thromboembolism were also evaluated . METHODS : Patients received a daily subcutaneous injection of 2.5 mg fondaparinux for 3 to 5 wk postoperatively . In patients with a neuraxial or deep peripheral nerve catheter , the catheter was removed 36 h after the last fondaparinux dose . The next fondaparinux dose was administered 12 h after catheter removal . The primary end points were symptomatic venous thromboembolism and major bleeding up to 4–6 wk after surgery . RESULTS : We recruited 5704 patients . A neuraxial or deep peripheral nerve catheter was inserted in 1553 ( 27 % ) patients and 78 ( 1.4 % ) patients , respectively . The rate of venous thromboembolism was 1.0 % ( 54 of 5387 ) . There was no difference between patients without ( 1.1 % ) or with ( 0.8 % ) a catheter ( the upper limit of the 95 % confidence interval of the odds ratio , 1.49 , being below the predetermined noninferiority margin of 1.75 ) . The incidence of major bleeding was 0.8 % ( 42 of 5382 ) . No neuraxial or perineural hematoma was reported . CONCLUSIONS : Once-daily subcutaneous injection of 2.5 mg fondaparinux given for 3 to 5 wk was effective and safe for prevention of venous thromboembolism after major orthopedic surgery . Temporary discontinuation of fondaparinux for 48 h permitted safe removal of a neuraxial or deep peripheral nerve catheter without decreasing thromboprophylatic efficacy
The results showed that , compared with placebo , pethidine , fentanyl , dexmedetomidine , and sufentanil significantly reduced the incidence of perioperative shivering .
In addition , compared with sufentanil , fentanyl showed no impact on haemodynamic stability and the incidence of pruritus .
CONCLUSION Pethidine , fentanyl , dexmedetomidine , and sufentanil appear to be effective for preventing perioperative shivering in puerperae undergoing cesarean sections .
Considering the risk-benefit profiles of the included neuraxial adjuvants , fentanyl is probably the optimal choice
BACKGROUND Perioperative shivering is clinical ly common during cesarean sections under neuraxial anesthesia , and several neuraxial adjuvants are reported to have preventive effects on it .
However , the results of current studies are controversial and the effects of these neuraxial adjuvants remain unclear .
AIM To evaluate the effects of neuraxial adjuvants on perioperative shivering during cesarean sections , thus providing an optimal choice for clinical application .