Hasty caesarean anaesthesia

Yentis and co. from St Marys in London (Anaesthesia, March 08) compared alkalinized lignocaine and adrenaline with 0.5% levobupivacaine for epidural anaesthesia for emergency caesarean section with catheters already in place for labour analgesia. It was one of those rare studies in that it was terminated earlier than planned because of the clear superiority of the lignocaine mix in providing rapid anaesthesia and more effective anaesthesia. It also prompted an urgent change in practice for the St Marys group because the 0.5% levobupivacaine had been the standard drug for emergency epidural anaesthesia.
By 12 minutes after 20 ml (given over 3 min) 95% of subjects in the lig/adr/bic were blocked to T5, but only 35% in the levobupivacaine group. And after 30 min ~20% of the levobupivacaine group were administed another form of anaesthesia.
20 ml over 3 min may seem to some a large and rapid bolus (I often use 15 ml of lig/adr/bic over 2-3 min), but the study did not experience any excessively high blocks. A firm, careful push over 2-3 min may expand the block to the desired upper thoracic dermatomes, whereas an intermittent dribble over 10 min results in the bolus dribbling out of the intervertebral foramina.

In the same issue, Bogod and his computer nerds in the Nottingham lab used computer simulation to conclude that 2 minutes of tidal volume breathing is superior to vital capacity breaths in maximising oxygenation. But the facemask must be tight!