Perioperative Ketorolac-lidocaine in the Patients With Valvular Heart Diseases During Cesarean Delivery

All parturients will receive oral ranitidine 150 mg on the night and the morning of surgery and 30 mL of 0.3 mol/L sodium citrate, 15 min before induction. All operations will be performed by the same obstetricians. Voluven 6% solution 7 mL/kg will be infused over 30 min. Left uterine displacement will be maintained before induction. All routine medications except angiotensin-converting enzyme inhibitors will be continued until the morning of the operation. All patients will be monitored with pulse oximetry, non-invasive blood pressure and five leads electrocardiography (leads II and V5). A radial artery catheter and a central venous catheter will be placed under local anesthesia before induction. On-screen pressure tracing will be used to determine end-expiration, and the CVP will be averaged over three respiratory cycles to eliminate respiratory artifacts. All staff in the operating room will be unaware of the randomization code. After pre-oxygenation for 5 min, a rapid sequence induction will be performed with propofol 1-2.5 mg/kg and suxamethonium 1.5 mg/kg. Cricoid pressure will be applied, laryngoscopy will be performed after the 1-min blood pressure recording, and tracheal intubation will be completed before the 2-min reading. Anesthesia will be maintained with end-tidal concentrations of 2-2.5% of sevoflurane, in combination with 50% nitrous oxide in oxygen and cisatarcurium 0.1-0.2 mg/kg. The patients' lungs will be ventilated to maintain an EtCO2 of 4-4.6 kPa. After the umbilical cord was clamped, infusion of 5-10 U oxytocin, midazolam 0.05 mg/kg and fentanyl 1-2 µg/kg will be given and nitrous oxide will be increased to 70%. Sevoflurane will be discontinued at the start of skin closure and the nitrous oxide will be discontinued after the last skin suture will be applied. At the end of surgery, residual neuromuscular block will be antagonized with neostigmine 50 µg/kg and atropine 20 µg/kg, and trachea will be extubated. Intraoperative hypertension, defines as increase in mean arterial blood pressure (MAP) \>= 25% of baseline for more than 1 min, with or without associated tachycardia (defined as HR value \> 20% of the baseline value \> 2 min) will be treated with IV boluses of fentanyl (1μg/kg). If blood pressure levels do not reach at least 20% of baseline levels after 5 min, slow intravenous administration of labetalol 20 mg will be considered. In the presence of hypotensive episodes (MAP decreased to \<= 60 mmHg \>= 2-3 min) and CVP \< 8 mmHg, 5-7 ml/kg of 6% hydroxyethyl starch 130/0.4 will be given. In the presence of MAP ≤ 60 mmHg, and CVP \> 10 mmHg, repeated bolus doses of ephedrine 5 mg will be given 5 min apart from each dose. Tachycardia ≥ 20% from the baseline values for ≥ 1 min will be treated with boluses of esmolol 20 mg.