Purpose: To describe the anaesthetic management and report the incidence of PDPH in three parturients who had experienced accidental dural puncture during labour and the subsequent deliberate intrathecal insertion of an epidural catheter.Clinical features: Inadvertent dural puncture with a 16-gauge Tuohy needle occurred during the first stage of labour at 3-4 cm cervical dilatation in all three women. The 20-gauge epidural catheter was immediately inserted into the subarachnoid space after accidental dural penetration. Intermittent intrathecal injections of lidocaine or bupivacaine with fentanyl were administered to provide analgesia during labour and delivery. Two of the women had spontaneous vaginal deliveries, whereas Caesarean section was performed in one case due to acute fetal distress during the second stage of labour. The intrathecal catheter was left in-situ for 13-19 hr after delivery and the women were questioned daily for symptoms of PDPH. None of the three women developed PDPH after dural puncture and intrathecal catheterisation with the epidural catheter.Conclusion: Immediate intrathecal insertion of the epidural catheter after accidental dural puncture during labour proved to be an effective prophylactic technique to prevent PDPH in these three parturients.Objectif : l~voquer la conduite anesth&ique et rincidence de la c6phal6e postponction dure-m&ienne (CPPDM) chez trois parturientes dont la dure-m&e a EtE ponctionnEe pendant le travail et chez qui on a ins&E un catheter sous-arachnofdien.Elements c]iniques : La dure-m&e a EtE ponctionnEe accidentellement avec une aiguille Tuohy 16G pendant le premier stage du travail alors que la dilatation &air ~ 3-4 cm chez les trois femmes. Un catheter Epidural 20G a &E introduit dans l'espace sous-arachnofdien immEdiatement apt& la ponction. Des injections sous-arachno'idiennes de lidocafne ou de bupivaca'fne avec du fentanyl ont EtE effectuEes pour procurer l'anesthEsie pendant le travail et l'accouchement. Deux des femmes ont accouch~ spontan(~ment par voie vaginale, alors que la troisiEme a dfi subir une cEsarienne ~ cause d'une dEtresse foetale survenue pendant le deuxiEme stage du travail. On a laissE le catheter sous-arachno'(dien en place pendant 13 ~ 19 h awes l'accouchement et recherche ~ chaque jour les sympt6mes de CPPDM. Aucune des trois femmes n'a dEveloppE de CPPDM aprEs la ponction de la duremere et l'insertion du catheter Epidural.Conclusion : l'insertion immediate d'un catheter Epidural awes une ponction accidentelle de la dure-mEre pendant le travail s'est avErEe une technique prophylactique efficace ~ prEvenir la CPPDM chez ces trois parturientes.

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Preoperative tumescent infiltration with lidocaine results in reduced pain and lower postoperative opioid requirements in the initial hours after reduction mammoplasty.

Purpose: To determine, after Caesarean delivery, uterine contractility and blood pressure following intravenous (iv) and intramyometrial (imy)injection of oxytocin. Methods: In a double-blind clinical trial 40 parturients scheduled for elective Caesarean section with spinal anaesthesia were randomized into two equal groups. One litre Ringer's lactate was administered iv before intrathecal injection of 1.7 ml bupivacaine 0.75% and 0.3 mg morphine. All patients received simultaneous iv and irny injections after removal of the placenta. Patients in Group I received 5 IU (I 0 IU'ml -~) oxytocin iv and 2 ml saline imy; Group 2 patients received 0.5 ml saline iv and 20 IU oxytocin into the myometrium. Baseline systolic blood pressure (SBP) and heart rate were measured before delivery and at one minute intervals for 15 min after injection of study solutions. Uterine contractility was assessed at I, 2, 4, 6, 8, 10 and 15 min after oxytocin injection. Haemoglobin concentration before surgery and on first post-operative day was also recorded. Results: Mean decrease in systolic blood pressure (SBP) one minute after oxytocin was 8.4 mmHg in Group I vs 14.6 mmHg in Group 2 (P < 0.001 ). Systolic blood pressure returned to baseline two minutes after oxytocin in Group I and after three minutes in Group 2. Uterine contractility and change in haemoglobin concentration were similar in both groups. Conclusion: Intramyometrial administration of 20 IU oxytocin after Caesarean delivery is associated with more severe hypotension than is iv injection of 5 IU oxytocin. Route of oxytocin injection did not affect uterine tone. R&ultats : La baisse moyenne de la tension art&ielle systolique (TAS), une minute apr& rinjection d'ocytocine, Etait de 8,4 mmHg dans le groupe I vs 14,6 mmHg dans le groupe 2 (P < 0,001 ). Egalement apr& rocytocine, il a fallu deux minutes pour le groupe I et trois minutes pour le groupe 2 avant de retrouver la tension art&ielle de base. La contractilitE uterine et le changement dans la concentration d'hEmoglobine ont EtE similaires dans les deux groupes. Conclusion : IJadministration intramyom&riale de 20 UI d'ocytocine aprEs une c&arienne est associEe ~ une hypotension plus sEv&e qu'avec une injection iv de 5 UI d'ocytocine. La voie d'administration de rocytocine n'a pas affectE la tonicitE uterine.