Joseph Shiber, MD, FAAEM, FACEP

• Associate Professor of Emergency Medicine, University of Central Florida
• School of Medicine, Research Director, Florida Hospital Emergency
• Medicine Residency, Orlando, FL, USA

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There is a brand new "ethics of normalcy" during which expectations about lengthy lives and routine medical therapies have come collectively. The irony is that such interventions delay debilitation, suffering, and the dying process, something which patients report they want to keep away from. The guidelines not only had a serious effect on scientific practice, research, and public health but in addition generated substantial controversy. Second, a advice for early preparation for arteriovenous fistula placement at 30 mL/min/1. Third, the advice of the upper vary of the target for erythropoietin of 13 g/dL, which subsequently was proven to be not useful and possibly harmful. These research explain how wellintentioned physicians can succumb to conflicts of interest and why the results of such conflicts are so insidious and tough to fight. They beneficial a formal process for discussing the conflicts of interest before clinical follow guideline growth. Consider using the "shock" query, "Would I be shocked if this patient died in the subsequent yr Screen for and manage emotional, psychosocial, and religious misery; refer to allied health professionals as acceptable. Educate regarding lively medical management without dialysis option as acceptable b. Consider initiating advance care planning on the time that patients are being educated with respect to renal substitute options if not done already. Ensure that household and different necessary individuals (as identified by the patient) are present for these discussions, especially the substitute decision-maker. Characterizing approaches to dialysis determination making with older adults: a qualitative study of nephrologists. Critical and honest conversations: the proof behind the "Choosing Wisely" campaign suggestions by the American Society of Nephrology. Quality of life and survival in patients with advanced kidney failure managed conservatively or by dialysis. Treatment depth on the finish of life in older adults receiving long-term dialysis. Derivation and validation of a prognostic mannequin to predict mortality in patients with superior persistent kidney illness. Revisiting the biomedicalization of growing older: medical developments and ethical challenges. In: the interest of patients: recommendations for doctor financial relationships and clinical determination making. Relationships between authors of medical practice guidelines and the pharmaceutical industry. Chronic Kidney Disease: a risk issue for dementia onset: a population-based research. Cross-sectional validity of a modified Edmonton symptom evaluation system in dialysis patients: a easy assessment of a symptom burden. It suits well with an individualized, patient-centered strategy to decision-making, not a disease-oriented strategy. Her household would really like her to begin dialysis as a outcome of they point out that she is healthy aside from the dementia which is progressing slowly and the kidney disease which she has recognized about for numerous years. Informed consent ought to embody disclosure that dialysis could not confer a survival benefit C. The doctor recommendation with regard to remedy is amongst the seven components of informed consent. The exhaustive literature evaluate minimizes the effect of financial conflicts of pursuits B. Disclosure of monetary conflicts of interests prevents subjectivity in guideline suggestions C. Studies on clinical follow pointers have discovered that virtually all authors have monetary relationships to pharmaceutical industries D. Disclosure additionally has not been discovered to limit subjectivity in guideline suggestions. Most authors concerned in scientific practice guideline improvement have financial conflicts of interest. Placement of an entry now is indicated to make positive that it has time to mature before use B.

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To ensure both maternal and fetal safety, the anesthesiologist must understand the physiologic impact of pregnancy on anesthetic administration (see Chapter 2) and function an lively member of the multidisciplinary team. Imaging research must be reviewed for placental location, anatomic information about the congenital lesion, and estimated fetal weight. This requires the anesthesiologist to balance the anesthetic wants of both sufferers, in addition to management uterine tone throughout the perioperative interval. Maternal analgesia and anesthesia may be provided by native infiltration, intravenous sedation, neuraxial anesthesia, common anesthesia, or a mix of these techniques, depending on the procedure, location of the placenta, and maternal co-morbidities. Fetal analgesia and anesthesia can be achieved via placental switch of anesthetic brokers given to the mother, by way of direct fetal intravenous (peripheral fetal vein or umbilical vein) or intramuscular administration of agents, or by a mixture of those strategies. An acceptable method of fetal monitoring and the potential requirement for fetal intravenous access and volume resuscitation during open surgical cases ought to be determined preoperatively. The operative team should be ready for emergency situations such as maternal hemorrhage, want for intrauterine fetal resuscitation. The surgical staff ought to be ready to immediately administer appropriate fetal weight-based intramuscular doses of atropine (20 �g/kg) and epinephrine (10 �g/kg), and carry out an emergent cesarean delivery if the gestational age is appropriate with extrauterine viability. The anesthesiologist must be ready to provide maternal common anesthesia if required. Tocolysis typically is pointless after cordocentesis or intrauterine transfusion. Supplemental maternal analgesia and anxiolysis could be achieved by maternal administration of an opioid, a benzodiazepine, and/or a low-dose propofol infusion, and should cut back fetal mobility by way of placental transfer of drug. However, neuraxial anesthesia is often used to minimize maternal movement, allow positioning, and supply sensory coverage for a quantity of percutaneous instrumentation websites or a mini-laparotomy. Fetal movement could additionally be hazardous for the fetus in cases of intrauterine transfusion, wire blood sampling, or thoracic shunt placement, because displacement of the needle or catheter could lead to trauma, bleeding, or compromise of the umbilical circulation. Placental switch of maternally administered opioids and benzodiazepines can scale back, however not necessarily eliminate, fetal movement. The onset of fetal paralysis occurs Anesthesia for Open Fetal Surgery When corrective fetal surgical procedure or an intrauterine process requires surgical entry via a hysterotomy, common anesthesia is typically administered. Unique concerns for open fetal procedures include the need for profound uterine leisure, intraoperative fetal monitoring, fetal anesthesia or analgesia, and postoperative maternal analgesia and uterine tocolysis (Box 7. In addition, important maternal and fetal blood loss could happen, and the anesthesiologist have to be ready to present maternal and fetal resuscitation. A excessive concentration of a risky halogenated agent is often administered to present both maternal and fetal anesthesia as properly as uterine relaxation. A last evaluation of the fetus is carried out, and the provision of all appropriate personnel, equipment, resuscitation medicines, and blood merchandise is confirmed earlier than induction. After administration of 100% oxygen and denitrogenation of the lungs, a rapid-sequence induction of general anesthesia with cricoid stress and endotracheal intubation is carried out. End-tidal carbon dioxide focus ought to be maintained at 28 to 32 mm Hg, which is normocarbic for pregnancy. An arterial catheter must be placed for maternal blood stress monitoring if uterine tocolysis with a nitroglycerin infusion is planned or if maternal hemodynamic instability occurs. Total intraoperative maternal intravenous fluids are restricted (less than 2 L) to cut back the danger for postoperative pulmonary edema. Some fetal surgery facilities administer colloid as a portion of the fluids to better maintain maternal blood pressure and/or select to restrict fluids even additional (less than 500 mL). No medical trials have confirmed a good factor about additional fluid restriction on this setting. Mean maternal arterial blood pressure is often maintained within 10% of baseline values and greater than 65 mm Hg. A phenylephrine infusion provides titratable blood stress management with minimal adjustments in the fetal acid-base standing. The uterus is assessed both visually and by palpation for contractions or increased tone. Further tocolysis may be achieved with intravenous nitroglycerin as an infusion or in bolus doses (100 �g).

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Metabolic results of a verylow-protein, low-phosphorus diet supplemented with essential amino acids and keto analogues in end-stage renal illnesses. Nutrition and consequence on renal substitute therapy of sufferers with persistent renal failure handled by a supplemented very low protein diet. Supplemented very low protein food regimen ameliorates responsiveness to erythropoietin in continual renal failure. Very low protein food plan supplemented with ketoanalogs improves blood pressure control in persistent kidney illness. Antioxidant effects of a supplemented very low protein food plan in continual renal failure. Effect of low-protein food regimen supplemented with keto acids on development of continual kidney disease. Metabolic acidosis and skeletal muscle adaptation to low protein diets in persistent uremia. The imply dietary protein intake at completely different phases of continual kidney illness is larger than present pointers. Early initiation of dialysis fails to delay survival in sufferers with end-stage renal failure. Creatinine, uric acid and different nitrogenous waste merchandise: clinical implication of the imbalance between their production and elimination in uremia. Pro: the rationale for dietary remedy for patients with advanced chronic kidney illness. Mechanisms allowing nephrotic sufferers to obtain nitrogen equilibrium with a protein-restricted food regimen. Safety and effectiveness of low-protein food regimen supplemented with ketoacids in diabetic sufferers with continual kidney illness. Protein food regimen restriction slows persistent kidney disease progression in non-diabetic and in sort 1 diabetic patients, but not in type 2 diabetic patients: a metaanalysis of randomized controlled trials using glomerular filtration fee as a surrogate. Urea excretion in adult people with varying degrees of kidney malfunction fed milk, egg or an amino acid combination: assessment of nitrogen stability. Navigating between the Scylla and Charybdis of prescribing dietary protein of persistent kidney diseases. The contradiction of secure body mass regardless of low reported dietary energy intake in persistent haemodialysis sufferers. Alterations of protein metabolism by metabolic acidosis in children with continual renal failure. Ammonium chloride-induced acidosis increases protein breakdown and amino acid oxidation in people. The impact of the correction of metabolic acidosis on nitrogen and protein steadiness of patients with persistent renal failure. Effects of long-term vitamin E supplementation on cardiovascular occasions and most cancers: a randomized controlled trial. Absorption, transport, and hepatic metabolism of copper and zinc: special reference to metallothionein and ceruloplasmin. Chronic metabolic acidosis decreases albumin synthesis and induces negative nitrogen stability in people. Chronic metabolic acidosis will increase the serum concentration of 1,25dihydroxyvitamin D in people by stimulating its manufacturing rate. Prescribe fat-soluble vitamins (vitamin A, D, E, and K) however not water-soluble nutritional vitamins B. Prescribe water-soluble vitamins (B-complex and C) but not fat-soluble nutritional vitamins C. Answer: Initiating hemodialysis earlier may be associated with higher cost and disease burden in contrast with medical management. Question 6 A 40-year-old man feels nicely however is anxious as a result of his S[Cr] has elevated from 2 to three mg/dL despite a prescribed diet of 0. The increase in S[Cr] might reflect kidney cell injury signified by granular casts within the urine sediment. The most typical causes are erythropoietin deficiency, iron deficiency, and inflammation.

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Total spinal block after epidural injection into an interspace adjoining to an inadvertent dural perforation. Effect of needle puncture on morphine and lidocaine flux via the spinal meninges of the monkey in vitro. Prophylactic vs therapeutic blood patch for obstetric patients with accidental dural puncture�a randomised managed trial. American Society of Regional Anesthesia and Pain Medicine checklist for managing native anesthetic systemic toxicity: 2012 model. Local anesthetics may be used for infiltration anesthesia, peripheral (pudendal) nerve block, or neuraxial block, whereas opioids are administered each systemically and neuraxially. The physiologic modifications that happen throughout pregnancy may have an result on the pharmacology of both local anesthetics and opioids. The intermediate alkyl chain, by virtue of its ester or amide linkage, is the premise for the classification of local anesthetics as amino-esters (which are hydrolyzed by pseudocholinesterase) and aminoamides (which undergo hepatic microsomal metabolism) (Table 13. The fragrant ring of the esters, which renders the molecule lipid soluble, is a by-product of benzoic acid. The tertiaryamine portion acts as a proton acceptor; thus, local anesthetics behave as weak bases. The Henderson-Hasselbalch equation predicts the relative proportions of local anesthetic that exist in the ionized and unionized kind. The higher the pKa (acid dissociation constant) relative to physiologic pH, the smaller the proportion of drug that exists in the un-ionized kind. All clinically used amide local anesthetics (with the exception of lidocaine) exist as stereoisomers because of an uneven carbon on the terminal amine. Clinical formulations of native anesthetics are prepared as hydrochloride salts to improve their solubility in water. The course by which the isomers rotate polarized light distinguishes them as either dextrorotary (d) or levorotary (l) isomers. The reduction in systemic toxicity observed with administration of the levorotary isomers may be each drug and concentration dependent. For instance, one research in isolated guinea pig hearts famous that bupivacaine isomers lengthened atrioventricular conduction time more than ropivacaine isomers did. In contrast to different measured variables, "atrioventricular conduction time confirmed evident stereoselectivity" for bupivacaine on the lowest concentration studied (0. This resting potential of 60 to 90 mV exists because the concentration of sodium in the extracellular house greatly exceeds that in the intracellular house. Excitation leads to the opening of membrane channels, which permits sodium ions to move freely down their focus gradient into the cell interior. Thus, the electrical potential within the nerve cell becomes much less unfavorable till, at the important threshold, rapid depolarization occurs. This depolarization is required to provoke the same sequence of events in adjoining membrane segments and for propagation of the action potential. Thereafter, sodium channels shut and the membrane as soon as again turns into impermeable to the influx of sodium. The negative resting membrane potential is reestablished as sodium is faraway from the cell by lively transport. Interference with sodium-ion conductance appears to be the mechanism by which local anesthetics reversibly inhibit the propagation of the motion potential. The most outstanding hypothesis is that the native anesthetic interacts with receptors within the nerve cell membrane involved in sodium conductance. As a rule, the levorotary isomer of a drug has larger vasoconstrictor activity and a longer duration of motion but less potential for systemic toxicity than the dextrorotary type. However, with improved techniques of selective extraction, two commercially available single-isomer formulations of local anesthetic are now available, ropivacaine and levobupivacaine. Ropivacaine is a homologue of mepivacaine and bupivacaine however is formulated as a single levorotary isomer rather than as a racemic combination. A propyl group on the pipechol ring distinguishes ropivacaine from bupivacaine (which has a butyl group) and mepivacaine (which has a methyl group).

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First, ache, uterine tenderness, and tachycardia have low sensitivity as diagnostic signs and indicators of lower uterine Use of Prostaglandins Lydon-Rochelle et al. Obstetricians sometimes discover an asymptomatic decrease uterine section scar dehiscence at the time of elective repeat cesarean supply. Of those that skilled uterine rupture, 5 of 14 patients (35%) with epidural analgesia experienced abdominal ache, in contrast with 4 of 23 patients (17%) without epidural analgesia. None of these investigators observed that epidural analgesia delayed the diagnosis of uterine rupture. Second, pain, uterine tenderness, and tachycardia have low specificity as diagnostic signs and indicators of decrease uterine section scar dehiscence. At surgery, they confirmed the presence of scar dehiscence in solely one of many 20 patients. In one report of six circumstances of uterine scar dehiscence or rupture, only one patient had intrapartum vaginal bleeding. Intravascular volume alternative promptly eradicated the differences between teams in maternal mean arterial strain, cardiac output, and fetal Pao2. However, there was a significant drop in maternal coronary heart price during hemorrhage within the animals that obtained epidural anesthesia. Fifth, up to now some obstetricians favored the use of epidural analgesia because it facilitates postpartum uterine exploration to assess the integrity of the uterine scar. Many obstetricians manage asymptomatic uterine scar dehiscence with "expectant remark. Thus, the provision and use of neuraxial analgesia may lower the incidence of pointless repeat cesarean supply. Department of Health and Human Services, Public Health Service, National Institutes of Health. Temporal pattern within the charges of trial of labor in low-risk pregnancies and their impression on the charges and success of vaginal delivery after cesarean supply. The strategy of cesarean section, with particular reference to the decrease uterine section incision. Elective repeat cesarean delivery versus trial of labor: a prospective multicenter examine. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. Comparison of maternal mortality and morbidity between trial of labor and elective cesarean section among ladies with earlier cesarean supply. Labor outcomes with increasing variety of prior vaginal births after cesarean delivery. American College of Obstetricians and Gynecologists Clinical Management Guidelines for Obstetricians-Gynecologists. The effect of birth weight on vaginal start after cesarean supply success rates. Safety and efficacy of vaginal birth after cesarean makes an attempt at or past 40 weeks of gestation. Vaginal start after cesarean or repeat cesarean part: medical dangers or social realities. Vaginal birth after cesarean section: the influence of patient resistance to a trial of labor. Counseling women with a previous cesarean birth: toward a shared decision-making partnership. Increased charges of cesarean sections and enormous families: a doubtlessly dangerous mixture. Validation of the prediction mannequin for fulfillment of vaginal delivery after cesarean delivery. Northwestern University Department of Obstetrics and Gynecology and Maternal-Fetal Medicine Units Network. Risk of uterine rupture during a trial labor in women with multiple and single prior cesarean supply. Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable possibility

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It is axiomatic that patient refusal represents an absolute contraindication to an elective procedure. A thorough preoperative assessment of current fetal well-being, maternal volume status, intrapartum systemic opioid use, antibiotic administration for ongoing chorioamnionitis or different infectious process, and a short reiteration of identified maternal disease states, including allergic reactions, will readily determine many of the major issues that might render neuraxial anesthesia potentially hazardous. The anesthesia provider ought to weigh the risks and benefits of neuraxial anesthesia for each affected person. Informed consent should embrace a frank discussion about anesthetic procedures and risks (see Chapter 32). Surveys of postpartum girls have demonstrated that almost all parturients want to know the potential complications of epidural analgesia, even these which are rare. A 2017 survey research of 206 postpartum ladies found no distinction in recall of dangers (discussed early after admission for labor) between women with and without pain on the time of the consent discussion. Most laboring ladies understand the necessity for informed consent, and so they respect the chance to participate in decisions about their care. Adequacy of consent may be demonstrated not only by documentation of information provided to the affected person but also by the lack of affected person objection to a process and the cooperation provided by the affected person in the course of the process. Interestingly, affected person and associate anxiousness, as measured by a validated nervousness questionnaire, have been much less when companions had been absent in the course of the process. However, most pregnant women are young, and youth often permits adequate flexibility to facilitate the insertion of a needle into the epidural or subarachnoid space. Whether the block is initiated in the lateral or sitting position is a matter of supplier and patient preference. Vincent and Chestnut22 carried out a examine during which they observed that neither the sitting nor the lateral position was constantly superior with regard to patient consolation. The sitting position is likely related to a better incidence of orthostatic hypotension and syncope. However, the sitting place is preferred-and could also be required-in obese parturients, in whom identification of the midline is normally considerably easier within the sitting position. Further, morbidly obese ladies may experience hypoxemia when positioned within the lateral decubitus position. One examine demonstrated a greater discount in maternal cardiac output with maximal lumbar flexion in the lateral decubitus position than in the sitting place during identification of the epidural house in laboring girls. They recommended that "the tight fetal curl position be prevented," particularly when the affected person assumes the lateral decubitus place. However, adoption of the lateral recumbent headdown place for epidural catheter placement might reduce the incidence of unintentional epidural venous puncture. Second, this place permits anesthesia providers to hold their elbows flexed, facilitating control of fantastic hand and wrist muscle movements. The incidence, timing, and extent of hypotension in the period immediately after initiation of the block depend on the kind of block. For example, when spinal anesthesia is initiated with a hyperbaric solution for instrumental vaginal delivery, it usually makes sense for the affected person to be sitting to ensure the speedy onset of sacral anesthesia. Conversely, spinal anesthesia for cervical cerclage may be initiated with the patient within the steep lateral Trendelenburg position with a hypobaric anesthetic solution. In comparison with the bolus administration of epidural local anesthetic, the extent of blockade could additionally be more gravity dependent when the anesthetic is run as a continuous infusion over a prolonged period. Some anesthesiologists contend that maternal place after epidural catheter placement affects the efficacy of epidural analgesia, though this is a matter of some dispute. However, there remain some circumstances during which a caudal technique is helpful and/or advantageous. It is an efficient selection for the second stage of labor in chosen sufferers in whom the lumbar epidural approach is hazardous or contraindicated. In most circumstances, caudal anesthesia could be efficiently carried out with the patient in a lateral decubitus place. Aseptic Technique In the previous decade, there was growing appreciation for the importance of sterile technique and the gravity of infectious complications associated to neuraxial anesthesia. Infection of the epidural area tends to result in the formation of an abscess, mostly shaped by Staphylococcus aureus found within the epidermis of either the affected person or the anesthesia supplier.

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Blood stress lowering and main cardiovascular occasions in individuals with and with out continual kidney disease: meta-analysis of randomised managed trials. Correction of the anemia of end-stage renal disease with recombinant human erythropoietin. Sensitization to human leukocyte antigen before and after the introduction of erythropoietin. An replace on the impact of pre-transplant transfusions and allosensitization on time to renal transplant and on allograft survival. Hemodialysis access at initiation within the United States, 2005 to 2007: still "catheter first". Vascular entry type and threat of mortality in a nationwide potential cohort of haemodialysis sufferers. Associations between hemodialysis entry type and clinical outcomes: a scientific evaluation. Health standing as a potential mediator of the association between hemodialysis vascular access and mortality. Patients ought to have a transparent understanding of the scheduling and logistic necessities that might be expected and how new dietary restrictions might be needed. For chosen sufferers, due to either superior age or other vital co-morbid conditions, there must be an understanding that a conservative, symptom-based and comfort-driven strategy may be most popular. Patients should be started on dialysis earlier than they qualify for itemizing on the deceased donor waiting list D. This has the effect of prolonging the ready time for eventual transplantation and exposing patients to potential interval growth of dialysis-related morbid events, not uncommonly rendering them unsuitable for transplantation. All of the above Answer: E From the academic point of view, the affected person and household ought to have an inexpensive understanding of the useful and symptomatic penalties of progressive kidney failure. The hemoglobin concentration must be at targets defined by clinical apply pointers with out the necessity for transfusion B. There have been no significant variations in mortality between those assigned to earlier initiation (37. These vascular problems subsequently render future placement of noncatheter forms of entry more difficult. The program will have to have the infrastructure to provide robust and complete modality training to patients and their assist individuals. Because many patients with advanced chronic kidney disease current urgently with indicators and signs that require rapid dialysis implementation, an in-house education program is fascinating but requires an funding in a nurse educator on web site. In most centers, scheduling this process can be delayed, so careful planning is necessary. The house dialysis program should be supported by the dialysis supplier or hospital or institution, as applicable. Adequate staffing is critical to the success of the program, permitting time for training (which is usually one on one), and for meeting the rules in place for residence packages. Space for the home program can be important, with room for private training and for clinic visits. Depression usually ensues and is frequent in patients present process upkeep dialysis. More recent studies using large databases and controlling for all essential variables present related 5-year survival. This study, although unsuccessful in its recruitment efforts, supplies an necessary lesson, in that it clearly confirmed that given full information, patients desire a alternative of modality. More attention is being given to conservative care approaches in older sufferers, those with appreciable comorbidity and demented patients who will acquire little benefit from starting dialysis. Paranoid patients have anxieties and concern increased by being connected to a machine and will lash out at healthcare suppliers and even show harmful. A nonfunctioning peritoneum is more likely to be the case in somebody with a previous ruptured viscus, or someone with prior historical past of radiation to the abdomen. Those with extreme ascites from liver failure also are vulnerable to development of hypotension and hypovolemia from excessive fluid elimination. The prognosis is dictated by the underlying liver illness and not by the selection of dialysis modality.

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A pharmacokinetic approach to resolving spinal and systemic contributions to epidural alfentanil analgesia and side-effects. The results of electrical stimulation at different frequencies on perception and pain in human volunteers: epidural versus intravenous administration of fentanyl. Comparative spinal distribution and clearance kinetics of intrathecally administered morphine, fentanyl, alfentanil, and sufentanil. Neuraxial opioids for post-cesarean delivery analgesia: can hydromorphone exchange morphine Single-dose, sustained-release epidural morphine in the administration of postoperative pain after elective cesarean delivery: outcomes of a multicenter randomized managed study. Genetic variability of the mu-opioid receptor influences intrathecal fentanyl analgesia necessities in laboring ladies. A118G single nucleotide polymorphism of human mu-opioid receptor gene influences ache notion and patient-controlled intravenous morphine consumption after intrathecal morphine for postcesarean analgesia. Effect of dexamethasone on prevention of postoperative nausea, vomiting and ache after caesarean part: a randomised, placebo-controlled, double-blind trial. Metoclopramide for nausea and vomiting prophylaxis throughout and after Caesarean supply: a scientific evaluate and meta-analysis. P6 stimulation for the prevention of nausea and vomiting associated with cesarean supply under neuraxial anesthesia: a systematic evaluate of randomized controlled trials. The effect of the addition of ropivacaine or bupivacaine upon pruritus induced by intrathecal fentanyl in labour. The dose-response of intrathecal sufentanil added to bupivacaine for labor analgesia. Nonopioid mechanism of morphine modulation of the activation of 5-hydroxytryptamine kind three receptors. A blinded study using nalbuphine for prevention of pruritus induced by epidural fentanyl. Methylnaltrexone to stop intrathecal morphine-induced pruritus after Caesarean 247. Studies of the pharmacology and pathology of intrathecally administered 4-anilinopiperidine analogues and morphine in the rat and cat. Effects of intravenous or subarachnoid morphine on cerebral and spinal twine hemodynamics and antagonism with naloxone in canines. Clinical experience of long-term treatment with epidural and intrathecal opioids�a nationwide survey. Mental status change and aphasia after labor analgesia with intrathecal sufentanil/bupivacaine. Intrathecal fentanyl is superior to intravenous ondansetron for the prevention of perioperative nausea during cesarean delivery with spinal anesthesia. Advantages of intrathecal nalbuphine, in contrast with intrathecal morphine, after cesarean supply: an analysis of postoperative analgesia and adverse effects. Effects of epidural naloxone on pruritus induced by epidural morphine: a randomized managed trial. Ondansetron is as effective as diphenhydramine for remedy of morphine-induced pruritus after cesarean delivery. Specific enhancement by fentanyl of the results of intrathecal bupivacaine on nociceptive afferent but not on sympathetic efferent pathways in canines. Respiratory arrest in a parturient following intrathecal injection of sufentanil and bupivacaine. Respiratory arrest following intrathecal injection of sufentanil and bupivacaine in a parturient. Onset of labour epidural analgesia with low-dose bupivacaine and different doses of fentanyl. Maternal respiratory arrests, severe hypotension, and fetal misery after administration of intrathecal, sufentanil, and bupivacaine after intravenous fentanyl. Severe respiratory despair within the obstetric affected person after intrathecal meperidine or sufentanil.

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