The RESPITE trial: remifentanil intravenously administered patient-controlled analgesia (PCA) versus pethidine intramuscular injection for pain relief in labour: study protocol for a randomised controlled trial

Background The commonest opioid used for pain relief in labour is pethidine (meperidine); however, its effectiveness has long been challenged and the drug has known side effects including maternal sedation, nausea and potential transfer across the placenta to the foetus. Over a third of women receiving pethidine require an epidural due to inadequate pain relief. Epidural analgesia increases the risk of an instrumental vaginal delivery and its associated effects. Therefore, there is a clear need for a safe, effective, alternative analgesic to pethidine. Evidence suggests that remifentanil patient-controlled analgesia (PCA) reduces epidural conversion rates compared to pethidine; however, no trial has yet investigated this as a primary endpoint. We are, therefore, comparing pethidine intramuscular injection to remifentanil PCA in a randomised controlled trial. Methods/design Women in established labour, requesting systemic opioid pain relief, will be randomised to either intravenously administered remifentanil PCA (intervention) or pethidine intramuscular injection (control) in an unblinded, 1:1 individual randomised trial. Following informed consent, 400 women in established labour, who request systemic opioid pain relief, from NHS Trusts across England will undergo a minimised randomisation by a computer or automated telephone system to either pethidine or remifentanil. In order to balance the groups this minimisation is based on four parameters; parity (nulliparous versus multiparous), maternal age (<20, 20 < 30, 30 < 40, 40+ years), ethnicity (South Asian (Pakistani/Indian/Bangladeshi) versus Other) and induced versus spontaneous labour. The effectiveness of pain relief provided by each technique will be recorded every 30 min after time zero, until epidural placement, delivery or transfer to theatre, quantified by Visual Analogue Scale. Incidence of maternal side effects including sedation, delivery mode, foetal distress requiring delivery, neonatal status at delivery and rate of initiation of breastfeeding within the first hour of birth will also be recorded. Maternal satisfaction with her childbirth experience will be determined by a postpartum questionnaire prior to discharge from the delivery ward. Discussion The RESPITE trial’s primary outcome is the proportion of women who have an epidural placed for pain relief in labour in each arm. Trial Registration Current Controlled Trials registration number: ISRCTN29654603. Registered on 23 July 2013

Remifentanil patient controlled analgesia versus epidural analgesia in labour. A multicentre randomized controlled trial

Contains fulltext : 109349.pdf (publisher's version ) (Open Access)ABSTRACT: BACKGROUND: Pain relief during labour is a topic of major interest in the Netherlands. Epidural analgesia is considered to be the most effective method of pain relief and recommended as first choice. However its uptake by pregnant women is limited compared to other western countries, partly as a result of non-availability due to logistic problems. Remifentanil, a synthetic opioid, is very suitable for patient controlled analgesia. Recent studies show that epidural analgesia is superior to remifentanil patient controlled analgesia in terms of pain intensity score; however there was no difference in satisfaction with pain relief between both treatments. METHODS/DESIGN: The proposed study is a multicentre randomized controlled study that assesses the cost-effectiveness of remifentanil patient controlled analgesia compared to epidural analgesia. We hypothesize that remifentanil patient controlled analgesia is as effective in improving pain appreciation scores as epidural analgesia, with lower costs and easier achievement of 24 hours availability of pain relief for women in labour and efficient pain relief for those with a contraindication for epidural analgesia.Eligible women will be informed about the study and randomized before active labour has started. Women will be randomly allocated to a strategy based on epidural analgesia or on remifentanil patient controlled analgesia when they request pain relief during labour. Primary outcome is the pain appreciation score, i.e. satisfaction with pain relief.Secondary outcome parameters are costs, patient satisfaction, pain scores (pain-intensity), mode of delivery and maternal and neonatal side effects.The economic analysis will be performed from a short-term healthcare perspective. For both strategies the cost of perinatal care for mother and child, starting at the onset of labour and ending ten days after delivery, will be registered and compared. DISCUSSION: This study, considering cost effectiveness of remifentanil as first choice analgesia versus epidural analgesia, could strongly improve the care for 180.000 women, giving birth in the Netherlands yearly by giving them access to pain relief during labour, 24 hours a day. TRIAL REGISTRATION NUMBER: Dutch Trial Register NTR2551, http://www.trialregister.nl

The effect of LPG usage on performance and emissions at various compression ratios in a small engine

Tek silindirli, düşük güçlü benzinli motorlar hava soğutmalı olduğu için oldukça düşük sıkıştırma oranına sahiptir. Ayrıca bu motorlar hafif zengin karışım ile çalıştığından özgül yakıt tüketimleri ve egzoz emisyon değerleri yüksektir. Bu motorlar, yüksek sıkıştırma oranında oktan sayısı yüksek alternatif temiz yakıtlar ile çalıştırıldığında performans ve emisyonlar iyileştirilebilir. Bu çalışmada tek silindirli bir motorun sıkıştırma oranı 5:1’den 9:1’e artırılmış ve LPG ile çalıştırılarak performansını artırma olanakları deneysel olarak araştırılmıştır. Standart sıkıştırma oranında yapılan deneylerde LPG ile çalışmada, benzine göre önemli bir güç kaybı olmadan, özgül yakıt tüketimi ve egzoz emisyonlarında azalmalar görülmüştür. Maksimum sıkıştırma oranında, LPG ile çalışmada benzine göre güçte %32 artış, özgül yakıt tüketiminde %60 azalma, CO, HC ve CO2 emisyonlarında sırasıyla %91, %23 ve %5 azalma elde edilmiştir. Sonuçlar; düşük güçlü motorlarda yüksek sıkıştırma oranında LPG kullanımının, motor performansını önemli ölçüde artırdığını ve egzoz emisyonlarını azalttığını göstermektedir.Small engines with single cylinder are usually air cooled and for this reason they have very low compression ratio. In addition, as these engines run on slightly rich fuel-air mixture, their specific fuel consumption and emission values are high. Performance and emission values of these engines can be improved by running them on high octane alternative clean fuels at a higher compression ratio. In this study, a single cylinder engine was run on LPG by increasing its compression ratio from 5:1 to 9:1 and the possibility of improving its performance was investigated experimentally. The results showed that some decreases were seen in the specific fuel consumption and in exhaust emissions without any noticeable power loss when LPG was used instead of gasoline at the standard compression ratio. At the maximum compression ratio, the power of the engine while running on LPG was found to be more than that when running on gasoline by 32 %. At the same time, specific fuel consumption and CO, HC and CO2 emissions were all decreased by 60%, 91%, 23% and 5%, respectively.According to the results obtained, it can be said that usage of LPG at high compression ratio on small engines significantly improves the engine performance and decreases exhaust emissions

Peripartum cardiomyopathy : postpartum decompensation and use of non-invasive cardiac output monitoring

Q3Q2Reporte de caso66-85The utility of a non-invasive cardiac output monitor (NICOM™) in guiding the peripartum management and identification of postpartum complications in a patient with severe peripartum cardiomyopathy is reported. A 31-year-old nulliparous woman at 35 weeks of gestation presented with a three-week history of worsening dyspnea and progressive functional deterioration. A transthoracic echocardiogram showed severe left ventricular systolic dysfunction with an ejection fraction <20%. Cardiac status was monitored using NICOM™ during labor and delivery. The baseline values were: cardiac output 5.3 L/min, total peripheral resistance 1549 dynes.sec/cm5, stroke volume 42.1 mL and stroke volume variation 18%. She received early epidural analgesia during labor, titrated slowly with a loading dose of 0.0625% bupivacaine 10 mL and fentanyl 25 μg, followed by patient-controlled epidural analgesia (0.0625% bupivacaine with fentanyl 2 μg/mL, infusion at 10 mL/h, bolus dose 5 mL and lockout interval 10 min). After epidural drug administration, total peripheral resistance decreased, cardiac output increased, and satisfactory analgesia was obtained. She had an uneventful vaginal delivery with a forceps-assisted second stage after prophylactic administration of furosemide 20 mg. NICOM™ was discontinued after delivery. Fifteen hours post-delivery, the patient developed cardiogenic shock, which resolved after aggressive therapy with inotropes and furosemide. NICOM™ can be used to guide treatment during labor and delivery in patients with critical peripartum cardiomyopathy. We suggest that use of NICOM™ be extended into the postpartum period to detect signs of cardiac decompensation in such patients