Recent advances in intravenous anaesthesia

E-mail: timwpp{at}hotmail.com

Editor—I would like to respond to a section of Professor Sneyd's review article on ‘Recent advances in intravenous anaesthesia’.1 Despite an extensive and generally well researched review, I take issue with his comments on the use of propofol in obstetric anaesthesia.

He briefly dismisses propofol as being contraindicated for induction and maintenance of anaesthesia during Caesarean section. The two references cited to support this assertion are >10 yr old and do not represent current evidence and opinion.2 3 Propofol has been used more extensively in obstetric anaesthesia in recent years for induction and also maintenance of anaesthesia and evidence supports the benefits.4 5 Initial fears of minor changes in subtle neurobehavioural scores have not been found to be a clinical problem.

The statement that ‘propofol is not licenced for use in obstetric anaesthesia’ is a very weak argument to avoid administering it.6 It is well known that commercial considerations govern the decision of a drug company to apply for a licence for use in obstetrics and following instructions on the product characteristics would lead us to avoid thiopentone in doses >250 mg and also mixing local anaesthesia with opioids.

I am not suggesting that the use of propofol for Caesarean section is universal and a controversies meeting of the Obstetric Anaesthetists Association in March 2003 revealed only 25% support for the motion proposing it as the induction agent of choice.7 This, however, is a considerable increase from a 1997 survey of the same organization indicating that <2% admitted to having used it for Caesarean section. I conclude that propofol is a safe and efficacious alternative to thiopental and in the future may replace it.

T. Parris-Piper

Auckland, New Zealand


 
E-mail: robert.sneyd{at}pms.ac.uk

Editor—Dr Piper is unhappy with my approach to obstetric use of propofol. Certainly, the evidence is mixed and the small number of research-based reports available are inconclusive.

Abboud5 gave propofol for induction and maintenance of anaesthesia to 37 parturients and they and their babies fared no worse than the 37 controls. Gregory and colleagues8 felt that ‘a propofol infusion coupled with nitrous oxide appears to be a satisfactory technique for Caesarean section’. In contrast, Yau and colleagues3 concluded ‘a prolonged propofol infusion time before delivery may cause lower Neurologic and Adaptive Capacity Scores’. Celleno and colleagues2 reported that ‘infants in the propofol group had lower Apgar scores at 1 and 5 min and 25% of them had muscular hypotonus at 5 min’.

In support of propofol there is a certain amount of positive commentary9 but this appears to be practice-based rather than the accumulated distillate of a consistent body of research evidence. The reality is that we cannot be sure that propofol is safe in this application. What is certain is that it is specifically contraindicated for obstetric use by its manufacturer. This is rather different from simply unlicensed and leaves the practitioner in an exposed position if used this way, especially if the unlicensed use in a contraindicated situation has not been agreed with the recipient.

It may be that propofol is a suitable agent for obstetric use but available data do not support this assertion nor do 75% of obstetric anaesthetists.

J. R. Sneyd

Plymouth, UK

References

1 Sneyd JR. Recent advances in intravenous anaesthesia Br J Anaesth 2004; 93: 725–36[Abstract/Free Full Text]

2 Celleno D, Capogna G, Tomassetti M, Costantino P, Di Feo G, Nisini R. Neurobehavioural effects of propofol on the neonate following elective Caesarean section. Br J Anaesth 1989; 62: 649–54[Abstract]

3 Yau G, Gin T, Ewart MC, Kotur CF, Leung RK, Oh TE. Propofol for induction and maintenance of anaesthesia at Caesarean section. A comparison with thiopentone/enflurane. Anaesthesia 1991; 46: 20–3[ISI][Medline]

4 Gin T. Propofol during pregnancy. Acta Anaesthesiol Sin 1994; 32: 127–32.[Medline]

5 Abboud TK, Zhu J, Richardson M. Intravenous propofol vs thiamylal-isoflurane for Caesarean section—comparative maternal and neonatal effects. Acta Anaesthesiol Scand 1995; 39: 205–9[ISI][Medline]

6 Summary of Product Characteristics for ‘Diprivan 1%’ (AstraZeneca UK Ltd), 2001

7 Duggal K. Propofol should be the induction agent of choice for Caesarean section under general anaesthesia. Int J Obstet Anesth 2003; 12: 275–6[CrossRef][ISI][Medline]

8 Gregory MA, Gin T, Yau G, Leung RK, Chan K, Oh TE. Propofol infusion anaesthesia for Caesarean section. Can J Anaesth 1990; 37: 514–20[Abstract]

9 Russell R. Propofol should be the agent of choice for Caesarean section under general anaesthesia. Int J Obstet Anesth 2003; 12: 276–9[CrossRef][ISI][Medline]





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