Pharmacokinetics of levobupivacaine with epinephrine in transversus abdominis plane block for postoperative analgesia after Caesarean section.

BACKGROUND: Transversus abdominis plane block is increasingly used for post-Caesarean section analgesia. Cases of toxicity and the limited pharmacokinetic information during pregnancy motivated this study. The objective of the study was to characterise and compare the pharmacokinetics of levobupivacaine with epinephrine in tranversus abdominis plane block, in post-Caesarean section patients and healthy volunteers. METHODS: After approval by the Ethics Committee, we collected data from 12 healthy parturients after elective Caesarean section (Study 1) and data from 11 healthy male volunteers from a previous study (Study 2). Transversus abdominus plane block was performed under ultrasound guidance. The following injectates were used: levobupivacaine 0.25%, 20 ml with epinephrine 5 µg ml-1 (Study 1) per side; 20 ml of the same solution (unilateral block) (study 2). The plasma venous concentration of levobupivacaine was measured serially for 90 min. Pharmacokinetic parameters (volume of distribution, clearance, and absorption half-life) were estimated using a non-linear mixed effects model (NONMEM). Simulation in 1000 patients estimated the maximum concentration and the time to reach it after bilateral transversus abdominis plane block. RESULTS: Venous concentrations were below toxic levels (2.62 mg L-1). Levobupivacaine volume of distribution after Caesarean section was higher than in healthy volunteers [172 L (70 kg)-1 (95% confidence interval: 137-207) vs 94.3 L (70 kg)-1 (95% CI: 62-128); P<0.01]. Clearance and absorption half-life were similar. The simulation showed that maximum levobupivacaine concentration is lower and occurs later in postpartum patients (P<0.01). Postoperative analgesia was effective. CONCLUSIONS: Postpartum women reached relatively low plasma concentrations of levobupivacaine after transversus abdominal plane block given a volume of distribution 80% higher than volunteers, which could confer a greater margin of safety. CLINICAL TRIAL REGISTRATION: NCT02852720.

The effect of anti-emetic doses of dexamethasone on postoperative blood glucose levels in non-diabetic and diabetic patients: a prospective randomised controlled study.

There are few data regarding postoperative hyperglycaemia in non-diabetic compared with diabetic patients following postoperative nausea and vomiting prophylaxis with dexamethasone. Eighty-five non-diabetic patients and patients with type-2 diabetes were randomly allocated to receive intravenous dexamethasone (8 mg) or ondansetron (4 mg). Blood glucose levels were measured at baseline and then 2, 4 and 24 h following induction of anaesthesia. In non-diabetic patients, the mean (SD) maximum blood glucose was higher in those who received dexamethasone compared with ondansetron (9.1 (2.2) mmol.l(-1) vs. 7.8 (1.4) mmol.l(-1) , p = 0.04). In diabetic patients, the mean (SD) maximum blood glucose was also higher in those who received dexamethasone compared with ondansetron (14.0 (2.5) mmol.l(-1) vs. 10.7 (2.4) mmol.l(-1) , p < 0.01). Multivariate analysis demonstrated that dexamethasone administration was a significant predictor of maximum postoperative blood glucose increase (p < 0.01) after adjusting for potential confounders. There was no interaction between baseline blood glucose level, or presence or absence of diabetes, and dexamethasone administration. We conclude that dexamethasone increases postoperative blood glucose levels in both non-diabetics and diabetics.

Uterotonics, magnesium sulphate and antibiotics during childbirth and peripartum: Important obstetric drugs for the anaesthesiologist.

The main causes of maternal mortality are comorbidities, hypertensive pregnancy syndrome, obstetric haemorrhage, and maternal sepsis. For this reason, uterotonics, magnesium sulphate, and antibiotics are essential tools in the management of obstetric patients during labour and in the peripartum period. These drugs are widely used by anaesthesiologists in all departments, and play a crucial role in treatment and patient safety. For the purpose of this narrative review, we performed a detailed search of medical databases and selected studies describing the use of these drugs in patients during pregnancy, delivery and the pospartum period. Uterotonics, above all oxytocin, play an important role in the prevention and treatment of pospartum haemorrhage, and various studies have shown that in obstetric procedures, such as scheduled and emergency caesarean section, they are effective at lower doses than those hitherto accepted. We also discuss the use of carbetocin as an effective alternative that has a therapeutic advantage in certain clinical circumstances. Magnesium sulphate is the gold standard in the prevention and treatment of eclampsia, and also plays a neuroprotective role in preterm infants. We describe the precautions to be taken during magnesium administration. Finally, we discuss the importance of understanding microbiology and the pharmacology of antibiotics in the management of obstetric infection and endometritis, and draw attention to the latest trends in antibiotic regimens in labour and caesarean section.

[Impact on the implementation of patient controlled epidural analgesia for pain management during labor. A survey in a university hospital in Chile]. / Impacto de la implantación y desarrollo de la analgesia epidural administrada por la paciente para el tratamiento del dolor del parto. Encuesta en un hospital universitario en Chile.

OBJECTIVE: Analgesia for labor is a legal obligation in Chile. In our institution we implemented patient controlled analgesia for pain relief during labor. We describe the perception of the several professionals involved in the medical care of patients in labor in terms of effectiveness, usefulness, satisfaction, and safety. MATERIAL AND METHODS: A self-reported questionnaire was given to the professionals involved, and the obstetrical and neonatal outcomes were recorded along with the workload indices. Twenty-five structured questions were presented with a Likert type score to evaluate analgesia quality, workload of professionals involved, adverse effects, patient satisfaction, and healthcare workers satisfaction. Finally, a question was asked about the overall perception. RESULTS: We found that the overall perception of the analgesic technique was (mean) 6.0 (SD) (0.88). A decrease in the anesthesiologist workload was observed, without affecting obstetric outcomes. CONCLUSION: Considering the study design limitations, absence of knowledge of economical impact, and the satisfaction level of patients under standard epidural analgesia, we recommend the patient controlled analgesia technique due to its good obstetric outcomes, general satisfaction and workload decrease.

[Epidural and subarachnoid anesthesia and analgesia in adults: an update]. / Actualización en anestesia y analgesia epidural y subaracnoidea en adultos.

We present an update of the latest advances in clinical management and images of the most commonly used neuraxial techniques in epidural, subarachnoid, and combined spinal-epidural anesthesia and analgesia.

[Neuraxial analgesia during labor in a patient with Arnold-Chiari type I malformation and syringomyelia]. / Malformación de arnold-chiari tipo I con siringomielia, trabajo de parto y analgesia neuroaxial.

Chiari type I malformation is a caudal displacement of the cerebellum with tonsillar herniation through the foramen magnum, frequently associated with syringomyelia, a syndrome characterized by cyst-like cavities in the spinal cord; each of the conditions leads to characteristic neurologic abnormalities. Pregnant patients with these types of malformation are considered to have an increased risk of brainstem compression and/or progression of the disease during labor. We present the case of a patient in labor with a diagnosis of syringomyelia associated with Chiari type I malformation and describe the anesthetic management. The patient revealed during labor that she had syringomyelia associated with Chiari type I malformation, after having made no mention of it in previous history taking. Finally, we review the pathology observed in these patients.

Recomendación Clínica: "Recomendaciones para el manejo de pacientes con COVID-19 con indicación terapéutica de ventilación mecánica que eventualmente son conectados a máquinas de anestesia" / Recommendations for patient management with COVID-19 with therapeutic indication mechanical ventilation that eventually are connected to anesthesia machines

La pandemia de COVID-19 producida por SARS-CoV-2 actualmente en curso anticipa una gran demanda por ventiladores mecánicos (VM), ya que un porcentaje relevante de los contagiados cae rápidamente en insuficiencia respiratoria y requiere de cuidados intensivos. Anticipándose a ese exceso de demanda y considerando que es muy probable que el número actual de ventiladores mecánicos en las unidades de cuidados intensivos (UCI) sean insuficientes, se ha solicitado a la SACH un informe técnico en relación al uso de las máquinas de anestesia como VM.

[Prophylaxis and treatment of arterial hypotension during caesarean with spinal anaesthesia]. / Profilaxis y tratamiento de la hipotensión arterial en la cesárea con anestesia subaracnoidea.

Caesarean section is one of the most common surgical procedures worldwide. Arterial hypotension is the most prevalent adverse effect after spinal anaesthesia. Various methods have been used to prevent or treat hypotension. Since there is no treatment 100% effective by itself, a multimodal management is required to achieve an optimum balance and avoidance of hemodynamic imbalance. Strategies to avoid this side effect are analyzed on the basis of the best evidence available so far, summarized as mechanical factors, anesthetics, fluids and vasopressors. After spinal anaesthesia for caesarean section, the best strategy available for prevention of hypotension appears to be the combination of crystalloids along with an alpha 1 agonist vasopressor.

A randomized, prospective double-blind comparison of the efficacy of generic propofol (sulphite additive) with diprivan.

BACKGROUND AND OBJECTIVE: We compared the dose requirement and side effect profile of total intravenous anaesthesia using Diprivan to generic propofol at a specific anaesthetic target level utilizing the bispectral index monitor to determine efficacy differences between the two products. METHODS: Sixty women undergoing abdominal hysterectomy were induced with propofol 2 mg kg-1 and maintained with infusion (20-200 microg kg-1 min-1) adjusted to maintain a bispectral index of 50-65. Plasma propofol concentration was measured at 1 and 2 h post induction in 25 patients. RESULTS: Mean (SD) drug doses adjusted for weight and time were similar in the Diprivan and generic propofol groups: 90 (30) microg kg-1 min-1 vs. 90 (20) microg kg-1 min-1 respectively. Mean (SD) plasma propofol levels at 1 and 2 h were also similar (3.0 (1.0) microg mL-1 vs. 3.6 (1.4) microg mL-1, P = 0.2 and 3.0 (1.9) microg mL-1 vs. 3.4 (1.6) microg mL-1, P = 0.58). CONCLUSIONS: Diprivan and generic propofol have similar efficacy at a specified, bispectral index-defined, depth of anaesthesia.

Reversible nitrous oxide myelopathy and a polymorphism in the gene encoding 5,10-methylenetetrahydrofolate reductase.

We present a case of a patient who received nitrous oxide on two occasions within a period of 8 weeks and who subsequently developed a diffuse myelopathy, characterized by upper extremity paresis, lower extremity paraplegia and neurogenic bladder. Laboratory testing revealed hyperhomocysteinaemia and low levels of vitamin B(12). Because of this uncommon clinical presentation, we analysed the patient's DNA, and found a polymorphism in the MTHFR gene that is associated with the thermolabile isoform of the 5,10-methylenetetrahydrofolate reductase enzyme, which explained the myelopathy experienced by the patient after being exposed to nitrous oxide. Soon after initiating supplementary therapy with folic acid and vitamin B(12), the neurological symptoms subsided.

Dural ectasia: a likely cause of inadequate spinal anaesthesia in two parturients with Marfan's syndrome.

We report two cases of Caesarean section in patients with Marfan's syndrome where continuous subarachnoid anaesthesia failed to provide an adequate surgical block. This was possibly because of dural ectasia, which was confirmed by a computed tomography scan in both cases.

Profilaxis y tratamiento de la hipotensión arterial en la cesárea con anestesia subaracnoidea / Prophylaxis and treatment of arterial hypotension during caesarean with spinal anaesthesia

La cesárea es uno de los procedimientos quirúrgicos más frecuentes a nivel mundial. La hipotensión arterial es el efecto adverso más prevalente tras una anestesia subaracnoidea. Se han utilizado diversos métodos para prevenirla o tratarla, para lograr un óptimo equilibrio hemodinámico. Al no hallar ninguno que sea 100% efectivo por sí solo, es necesario el tratamiento multimodal para lograr el objetivo deseado. Las estrategias para evitar este efecto colateral se analizaron a la luz de la mejor evidencia disponible hasta ahora, resumidas como factores mecánicos, anestésicos, líquidos y vasopresores. Tras anestesia subaracnoidea para la cesárea, la mejor estrategia disponible hoy para prevención de hipotensión arterial parece ser el uso de carga de cristaloides conjuntamente con un vasopresor alfa agonista tipo 1 (AU)

Caesarean section is one of the most common surgical procedures worldwide. Arterial hypotension is the most prevalent adverse effect after spinal anaesthesia. Various methods have been used to prevent or treat hypotension. Since there is no treatment 100% effective by itself, a multimodal management is required to achieve an optimum balance and avoidance of hemodynamic imbalance.Strategies to avoid this side effect are analyzed on the basis of the best evidence available so far, summarized as mechanical factors, anesthetics, fluids and vasopressors. After spinal anaesthesia for caesarean section, the best strategy available for prevention of hypotension appears to be the combination of crystalloids along with an alpha 1 agonist vasopressor (AU)

Actualización en anestesia y analgesia epidural y subaracnoidea enadultos / Epidural and subarachnoid anesthesia and analgesia in adults: an update

Se presenta una puesta al día actualizada de los últimosavances en manejo clínico e imágenes de las técnicasneuroaxiales más utilizadas en la actualidad: anestesiay analgesia epidural, subaracnoidea y la combinadaespinal-epidural (AU)

We present an update of the latest advances in clinicalmanagement and images of the most commonly usedneuraxial techniques in epidural, subarachnoid, andcombined spinal-epidural anesthesia and analgesia (AU)

Malformación de Arnold-Chiari tipo I con siringomielia, trabajo de parto y analgesia neuroaxial / Neuraxial analgesia during labor in a patient with Arnold-Chiari type I malformation and syringomyelia

La malformación de Chiari tipo I es un desplazamientocaudal del cerebelo con herniación amigdalinapor debajo del foramen magno, frecuentemente asociadocon la siringomielia, un síndrome caracterizado por lapresencia de cavidades quísticas dentro de la médulaespinal; cada una de las cuales produce alteraciones neurológicascaracterísticas. Se considera que las pacientesembarazadas con este tipo de malformaciones tienen unriesgo aumentado de enclavamiento y/o progresión de laenfermedad durante el trabajo de parto. Presentamos elcaso de una paciente en trabajo de parto con el diagnósticode siringomielia con una malformación de Chiaritipo I asociada y el manejo anestésico. Al ingreso no refirióantecedentes, sin embargo, durante el parto reveló elhecho de tener una siringomielia y malformación deChiari tipo I asociada. Finalmente, realizamos una revisiónde la patología en esta población en particular

Chiari type I malformation is a caudal displacement of ;;the cerebellum with tonsillar herniation through the ;;foramen magnum, frequently associated with syringomyelia, ;;a syndrome characterized by cyst-like cavities in the spinal ;;cord; each of the conditions leads to characteristic neurologic ;;abnormalities. Pregnant patients with these types of ;;malformation are considered to have an increased risk of ;;brainstem compression and/or progression of the disease ;;during labor. We present the case of a patient in labor with ;;a diagnosis of syringomyelia associated with Chiari type I ;;malformation and describe the anesthetic management. The ;;patient revealed during labor that she had syringomyelia ;;associated with Chiari type I malformation, after having ;;made no mention of it in previous history taking. Finally, we ;;review the pathology observed in these patients

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