Pre-emptive intramuscular (i.m.) vasopressors were evaluated in 108 patients undergoing elective Caesarean section under spinal anaesthesia, assigned to four groups in a randomized, double-blind, placebo-controlled study. Group 1 received pre-emptive phenylephrine 4 mg i.m., group 2 received phenylephrine 2 mg i.m., group 3 received ephedrine 45 mg i.m., while controls received an i.m. injection of saline, all given immediately after induction of spinal anaesthesia. Hypotension was defined as a 25% decrease in mean arterial pressure (MAP). Rescue intravenous (i.v.) boluses of ephedrine were given if the patient was hypotensive or reported nausea, vomiting or dizziness. The incidence of hypotension was 33% in the phenylephrine 4 mg group compared with 70% in the control and phenylephrine 2 mg groups (P=0.03), and 48% in the ephedrine 45 mg group. The phenylephrine 4 mg and ephedrine 45 mg groups had a significantly lower percentage reduction in MAP (-21 (SD 14)% and -22 (14)%) compared with controls (-32 (18)%, P=0.04). They also had a lower total dose of rescue i.v. ephedrine (15.7 (15.7) mg and 15.8 (15.6) mg) compared with controls (28.8 (20.6) mg, P=0.02). We conclude that pre-emptive i.m. phenylephrine 4 mg and ephedrine 45 mg reduce the severity of hypotension and the total dose of rescue i.v. ephedrine during spinal anaesthesia for Caesarean section.

Pregnancy in a patient in a persistent vegetative state presents challenging therapeutic questions about the level of supportive management required, the assessment of fetal well-being, the timing and mode of delivery and the anaesthetic management of labour and delivery. We report the case of a 29-yr-old woman who had a favourable fetal outcome despite suffering hypoxic brain damage after a suicide attempt by a drug overdose. She was managed until the onset of labour on an intensive care unit and had a spontaneous vaginal delivery assisted by epidural anaesthesia.

We have evaluated a new method of assessing dermatomal sensory levels after regional anaesthesia based on warm sensation. Sensory levels were assessed in 30 patients after spinal anaesthesia using a respiratory gas humidifier, adapted to deliver a constant flow of warm air at 40 +/- 0.2 degrees C. This was compared with the cold sensation from ethyl chloride spray. The frequency distribution of the dermatomal differences showed 96.6% of the comparisons were between +1 and -1 dermatomes. The median difference in dermatomal levels between the two methods of assessment was 0 (interquartile range 0-1) (P = 0.65). We conclude that the warm air method compares favourably with ethyl chloride spray and both can be used interchangeably.

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