In the present study we evaluated whether the sitting position during initiation of small-dose combined spinal-epidural anesthesia (CSE) would induce less hypotension as compared with the lateral position. Sixty women undergoing elective cesarean delivery were randomly assigned to receive a spinal injection consisting of 6.6 mg hyperbaric bupivacaine with sufentanil 3.3 microg in either the lateral or the sitting position. After securing the epidural catheter, patients were turned to a 15 degrees left lateral supine position. Ephedrine 5 mg IV was administered prophylactically and subsequently in case of nausea/vomiting and/or hypotension, defined as a systolic blood pressure less than 95 mm Hg or a 25% decrease from baseline values. Although the incidence of ephedrine supplementation was not different, females in the sitting group required less ephedrine (P = 0.012) and there were fewer problems with identifying the epidural space (P = 0.01). However, more patients in this group required epidural supplementation (35% versus 3%; P = 0.007). In the lateral group, blocks extended more cephalad than with the sitting position (P = 0.014). Apgar scores did not differ, but umbilical artery pH values were significantly higher in patients of the sitting group (7.31 +/- 0.04 versus 7.26 +/- 0.03; P = 0.02). We conclude that performing a CSE technique for cesarean delivery in the sitting position was technically easier and induced less severe hypotension.

In coronary surgery patients the use of a volatile anesthetic regimen with sevoflurane was associated with a better recovery of myocardial function and less postoperative release of troponin I. In the present study we investigated whether these cardioprotective properties were also apparent in the cardiac surgical setting of aortic valve replacement (AVR) surgery for the correction of aortic stenosis. Thirty AVR surgery patients were randomly assigned to receive either target-controlled infusion of propofol or inhaled anesthesia with sevoflurane. Cardiac function was assessed perioperatively using a pulmonary artery catheter. Perioperatively, a high-fidelity pressure catheter was positioned in the left ventricle. Postoperative concentrations of cardiac troponin I were followed for 48 h. After cardiopulmonary bypass (CPB), stroke volume and dP/dt(max) were significantly higher in the patients with sevoflurane. Post-CPB, the effects of an increase in cardiac load on dP/dt(max) were similar to pre-CPB in the sevoflurane group (1.0 % +/- 5.4% post-CPB versus 1.3% +/- 8.6% pre-CPB) but more depressed in the propofol group (-8.2% +/- 4.4% post-CPB versus 0.1% +/- 4.9% pre-CPB). The rate of relaxation was significantly slower post-CPB in the propofol group. Postoperative levels of troponin I were significantly lower in the sevoflurane group. Our data indicate that the use of a volatile anesthetic regimen in AVR surgery was associated with better preservation of myocardial function and a reduced postoperative release of troponin I.

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