Central venous catheters for total parenteral nutrition (TPN) have traditionally been inserted via direct cannulation of the subclavian vein, but this technique requires physician participation and is associated with well-described complications. We report the single largest institutional experience with peripherally inserted central venous catheters (PICC lines) used exclusively for TPN in non-intensive care unit patients. From July 1991 to March 1994, 135 PICC lines were placed in 126 patients via the antecubital vein, advanced into the central venous system, and used only for TPN. Complication rates were determined and compared with those for TPN administered through a subclavian vein-inserted central catheter. Patient demographics were similar in each group with respect to age, type of disease process, acuity of illness, and indications for nutrition support. A cumulative number of 1381 TPN days (mean = 11 days per patient) comprised the PICC line experience. Comparison was made with 135 successive standard (subclavian) central lines inserted in 105 patients for TPN administration (1056 TPN days, mean = 10 days per patient). There was no difference in the overall rate of complications between the two groups. There were no major complications that prolonged hospitalization (eg, catheter-related sepsis or pneumothorax) in the PICC group compared with three such complications in the standard group. PICC lines can be used safely and effectively for TPN and are associated with an acceptable rate of complications.

Epidural analgesia is the most effective and innocuous technique for obstetrics. Pain relief is its main indication but maternal diseases that might be decompensated by labour and delivery are also accepted indications. Low doses of long-acting local anaesthetics alone or in combination with low doses of fentanyl or sufentanil provide good quality analgesia and are safe for mother and fetus. Test doses in parturients lack suf®cient speci®city and sensitivity for detecting inadvertent intravascular injection, and subarachnoid migration of the catheter is possible at any time during the procedure. Therefore, every injection must be considered as a test dose and only fractionated injections must be made. Epidural block to T10 is needed for labour and to level T4 for Caesarean section. Maintenance of the block with a continuous infusion, or patient-controlled epidural analgesia with a background continuous infusion, provides more stable analgesia than by intermittent injection. Technical dif®culties, dural tap, bloody tap, hypotension and insuf®cient block are most frequent complications of epidural block in obstetrics. Excessive motor block prolongs the second stage of labour and increases the frequency for instrumental delivery and is therefore considered a complication

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Epidural analgesia is the most effective and innocuous technique for obstetrics. Pain relief is its main indication but maternal diseases that might be decompensated by labour and delivery are also accepted indications. Low doses of long-acting local anaesthetics alone or in combination with low doses of fentanyl or sufentanil provide good quality analgesia and are safe for mother and fetus. Test doses in parturients lack sufficient specificity and sensitivity for detecting inadvertent intravascular injection, and subarachnoid migration of the catheter is possible at any time during the procedure. Therefore, every injection must be considered as a test dose and only fractionated injections must be made. Epidural block to T10 is needed for labour and to level T4 for Caesarean section. Maintenance of the block with a continuous infusion, or patient-controlled epidural analgesia with a background continuous infusion, provides more stable analgesia than by intermittent injection. Technical difficulties, dural tap, bloody tap, hypotension and insufficient block are most frequent complications of epidural block in obstetrics. Excessive motor block prolongs the second stage of labour and increases the frequency for instrumental delivery and is therefore considered a complication.

A case of a 36-year-old woman diagnosed brain dead secondary to pneumococcal meningitis at 27 weeks of gestation is presented. In spite of aggressive therapy, supportive intensive care was possible for only 36 h. Signs of fetal distress appeared and a cesarean section was performed. The complexity of supportive care and its ethical implications are discussed.