Possible formation of pulmonary microthrombi in the early puerperium of pregnant women critically ill with COVID-19: Two case reports.

BACKGROUND: Limited data are available on the management of pregnant women with severe or critical forms of COVID-19, such as the optimal timing of provider-initiated delivery, and post-partum care, including antithrombotic prophylaxis. We present the clinical course, pre- and post-partum management, and outcomes of two pregnant women critically ill with COVID-19. CASES: Both women had confirmed SARS-CoV-2 pneumonia with rapid clinical decompensation that required admission to the intensive care unit, intubation, and delivery by emergency cesarean section at 32 and 29 weeks. Both patients clinically improved in the first two postoperative days, but this was followed by clinical, laboratory and radiological deterioration on the third postoperative day; however, they both improved again after full anticoagulation. This pattern suggests the possible formation of pulmonary microthrombi in the early puerperium. We discuss the challenges faced by the multiprofessional team in the management of these patients. CONCLUSIONS: There are few resources to guide health professionals caring for pregnant women with critical COVID-19. These two cases contribute to the rapidly evolving knowledge on the management and outcomes of pregnant women with COVID-19.

Non-multidrug-resistant, methicillin-resistant Staphylococcus aureus in a neonatal unit.

BACKGROUND: In the last decade, non-multiresistant methicillin-resistant Staphylococcus aureus (NM-MRSA) has been described as an important agent in bloodstream infections in our hospital. METHODS: This prospective cohort study, conducted from February 2009 through January 2010 in the neonatal unit, evaluated 403 newborns (NB), their 382 mothers and 148 health care workers (HCW). RESULTS: Approximately 217 NB (54%), 187 mothers (48%) and 87 HCW (59%) were colonized by S. aureus (SA). MRSA colonization was greater among NB (15%) than mothers (4.7%) and HCW (3.4%). Although mother-to-NB transmission occurred, in most cases mothers were not responsible for NB colonization. There were 2 predominant PFGE patterns among the NB and some mothers and HCW became colonized by them. Factors significantly associated with MRSA carriage by NB were lower level of maternal schooling (risk factor: odds ratio: 2.99; 95% confidence interval: 1.10-8.07) and maternal rhinosinusitis (protective factor: odds ratio: 0.33; 95% confidence interval:0.12-0.88). Among NB who remained hospitalized for more than 72 hours, breast feeding was protective (odds ratio: 0.22; 95% confidence interval: 0.05-0.98). All the isolates were NM-MRSA, carried few virulence factors and SCCmec types IVa and type IVd predominated. CONCLUSIONS: Although there were no cases of infection, nosocomial transmission of MRSA clearly occurred in the neonatal unit, and this highlights the need for infection control practices such as hand hygiene to prevent cross-dissemination. Other healthcare practices, which are very basic but also ample in scope, may play a role, such as general education of women and breast feeding.

Performance of surveillance cultures at different body sites to identify asymptomatic Staphylococcus aureus carriers.

The objective was to evaluate the performance of surveillance cultures at various body sites for Staphylococcus aureus colonization in pregnant women and newborns (NB) and the factors associated with nasal colonization. For NB, 4 sites were evaluated: nares, oropharynx, perineum, and umbilical stump (birth, third day, and weekly). For pregnant women, 4 sites during labor: anterior nares, anus, perineum, and oropharynx. Nasally colonized patients were compared with colonized only extranasally. Colonization was 53% of 392 pregnant women (methicillin-resistant S. aureus [MRSA]: 4%) and 47% of 382 NB (MRSA: 9%). For newborn patients, the best body site was the umbilical stump (methicillin-susceptible S. aureus [MSSA]: 64%; MRSA: 68%) and the combination of nares + umbilical (MSSA: 86%; MRSA: 91%). Among pregnant women, the best body site was the anterior nares (MSSA: 59%; MRSA: 67%) and the combination of nares + oropharynx (MSSA: 83%; MRSA: 80%). A smaller number of household members were associated with MRSA carriage in pregnant women (2.2 ± 0.6 versus 3.6 ± 1.8; P = 0.04). In conclusion, multiple culture sites are needed. Control programs based on surveillance cultures may be compromised.

Clinical evaluation of the flotrac/Vigileo system for continuous cardiac output monitoring in patients undergoing regional anesthesia for elective cesarean section: a pilot study.

BACKGROUND: Spinal anesthesia for cesarean delivery may cause severe maternal hypotension and a decrease in cardiac output. Compared to assessment of cardiac output via a pulmonary artery catheter, the FloTrac/Vigileo system may offer a less invasive technique. The aim of this study was to evaluate cardiac output and other hemodynamic measurements made using the FloTrac/Vigileo system in patients undergoing spinal anesthesia for elective cesarean section. METHODS: A prospective study enrolling 10 healthy pregnant women was performed. Hemodynamic parameters were continuously obtained at 15 main points: admission to surgery (two baseline measurements), after preload, after spinal anesthesia administration and 4 time points thereafter (4, 6, 8 and 10 min after anesthesia), at skin and uterine incision, newborn and placental delivery, oxytocin administration, end of surgery, and recovery from anesthesia. Hemodynamic therapy was guided by mean arterial pressure, and vasopressors were used as appropriate to maintain baseline values. A repeated measures ANOVA was used for data analysis. RESULTS: There was a significant increase in heart rate and a decrease of stroke volume and stroke volume index up to 10 min after spinal anesthesia (P < 0.01). Importantly, stroke volume variation increased immediately after newborn delivery (P < 0.001) and returned to basal values at the end of surgery. Further hemodynamic parameters showed no significant changes over time. DISCUSSION AND CONCLUSIONS: No significant hemodynamic effects, except for heart rate and stroke volume changes, were observed in pregnant women managed with preload and vasopressors when undergoing elective cesarean section and spinal anesthesia.

Clinical evaluation of the flotrac/vigileo™ system for continuous cardiac output monitoring in patients undergoing regional anesthesia for elective cesarean section: a pilot study

BACKGROUND: Spinal anesthesia for cesarean delivery may cause severe maternal hypotension and a decrease in cardiac output. Compared to assessment of cardiac output via a pulmonary artery catheter, the FloTrac/Vigileo™ system may offer a less invasive technique. The aim of this study was to evaluate cardiac output and other hemodynamic measurements made using the FloTrac/Vigileo™ system in patients undergoing spinal anesthesia for elective cesarean section. METHODS: A prospective study enrolling 10 healthy pregnant women was performed. Hemodynamic parameters were continuously obtained at 15 main points: admission to surgery (two baseline measurements), after preload, after spinal anesthesia administration and 4 time points thereafter (4, 6, 8 and 10 min after anesthesia), at skin and uterine incision, newborn and placental delivery, oxytocin administration, end of surgery, and recovery from anesthesia. Hemodynamic therapy was guided by mean arterial pressure, and vasopressors were used as appropriate to maintain baseline values. A repeated measures ANOVA was used for data analysis. RESULTS: There was a significant increase in heart rate and a decrease of stroke volume and stroke volume index up to 10 min after spinal anesthesia (P < 0.01). Importantly, stroke volume variation increased immediately after newborn delivery (P < 0.001) and returned to basal values at the end of surgery. Further hemodynamic parameters showed no significant changes over time. DISCUSSION AND CONCLUSIONS: No significant hemodynamic effects, except for heart rate and stroke volume changes, were observed in pregnant women managed with preload and vasopressors when undergoing elective cesarean section and spinal anesthesia.

Effects of the addition of subarachnoid clonidine to the anesthetic solution of sufentanil and hyperbaric or hypobaric bupivacaine for labor analgesia.

BACKGROUND AND OBJECTIVES: The addition of subarachnoid clonidine (alpha-agonist) prolongs the analgesia produced by the combination of sufentanil and isobaric bupivacaine in combined labor analgesia(1). The objective of this study was to compare the quality of analgesia and the prevalence of side effects after the addition of subarachnoid clonidine to the anesthetic solution in labor analgesia. METHODS: After approval by the Ethics Commission, 22 pregnant women in labor were randomly assigned to the subarachnoid administration of either 2.5 mg of 0.5% hyperbaric bupivacaine (CLON/HYPER Group; n = 11) or 2.5 mg of 0.5% isobaric bupivacaine (CLON/ISO Group; n = 11) associated with 2.5 microg of sufentanil and 30 microg of clonidine. Pain, evaluated by the Visual Analogue Scale, heart rate, and mean arterial pressure were assessed every 5 minutes during the first 15 minutes, and then every 15 minutes afterwards until delivery. The prevalence of side effects (nausea, vomiting, pruritus, and sedation) was evaluated. The study was terminated whenever the patient needed supplemental epidural analgesia (pain > 3) or upon delivery of the fetus. The Student t test, Chi-square test, Fisher exact test, and two-way ANOVA for repeated measurements were used in the statistical analysis and a p < 0.05 was considered significant. RESULTS: Anthropometric data, duration of analgesia (70.9 +/- 32.9 vs. 85.4 +/- 39.5), heart rate, and the incidence of pruritus, sedation, nausea, and vomiting were similar in both groups. Mean arterial pressure was significantly lower in the CLON/ISO Group than in the CLON/HYPER Group at 15, 30, and 45 minutes (p < 0.05). CONCLUSIONS: Under the conditions of the present study, the association of a small dose of clonidine (30 microg) with sufentanil caused a higher incidence of hypotension when the isobaric solution of the local anesthetic was used. For all other side effects, both hyperbaric and isobaric solutions showed similar behavior.

Efeito da adição de clonidina subaracnóidea à solução anestésica de sufentanil e bupivacaína hiperbárica ou hipobárica para analgesia de parto / Efecto de la adición de clonidina subaracnoidea a la solución anestésica de sufentanil y bupivacaína hiperbárica o hipobárica para la analgesia de parto / Effects of the addition of subarachnoid clonidine to the anesthetic solution of sufentanil and hyperbaric or hypobaric bupivacaine for labor analgesia

JUSTIFICATIVA E OBJETIVOS: Adição de clonidina subaracnóidea (±-agonista) prolonga a ação analgésica da combinação sufentanil e bupivacaína isobárica em analgesia combinada para o trabalho de parto Õ. O objetivo deste estudo foi comparar a qualidade de analgesia e a prevalência de efeitos colaterais após a adição de clonidina subaracnóidea à solução anestésica em gestantes durante trabalho de parto. MÉTODO: Após aprovação da Comissão de Ética, 22 gestantes em trabalho de parto receberam aleatoriamente no espaço subaracnóideo 2,5 mg de bupivacaína hiperbárica 0,5 por cento (grupo CLON/HIPER; n = 11) ou 2,5 mg de bupivacaína isobárica 0,5 por cento (grupo CLON/ISO; n = 11) em associação ao sufentanil 2,5 µg e à clonidina 30 µg. A dor avaliada pela Escala Analógica Visual, a freqüência cardíaca e a pressão arterial média foram estudadas a cada 5 minutos nos primeiros 15 minutos e, a seguir, a cada 15 minutos até o nascimento. Foi avaliada a prevalência de efeitos colaterais (náusea, vômito, prurido e sedação). O estudo foi encerrado no momento em que foi necessária complementação analgésica peridural (dor > 3 cm) ou ao nascimento. A análise estatística foi realizada pelos testes t de Student, Qui-quadrado, Fisher e ANOVA de duas vias para medidas repetidas, considerando como significativo p < 0,05. RESULTADOS: Os grupos CLON/HIPER e CLON/ISO foram semelhantes com relação a dados antropométricos, duração da analgesia (70,9 ± 32,9 vs. 85,4 ± 39,5), freqüência cardíaca, ocorrência de prurido, sedação, náusea e vômitos. No grupo CLON/ISO houve diminuição significativa da pressão arterial média com relação ao grupo CLON/HIPER nos momentos 15, 30 e 45 minutos (p < 0,05). CONCLUSÕES: Nas condições estudadas, a adição de clonidina em baixa dose (30 »g), associada ao sufentanil, determinou maior ocorrência de hipotensão quando administrada com soluções isobáricas de anestésico local. Com relação aos demais efeitos colaterais, as soluções hiperbáricas...

BACKGROUND AND OBJECTIVES: The addition of subarachnoid clonidine (α-agonist) prolongs the analgesia produced by the combination of sufentanil and isobaric bupivacaine in combined labor analgesiaÕ. The objective of this study was to compare the quality of analgesia and the prevalence of side effects after the addition of subarachnoid clonidine to the anesthetic solution in labor analgesia. METHODS: After approval by the Ethics Commission, 22 pregnant women in labor were randomly assigned to the subarachnoid administration of either 2.5 mg of 0.5 percent hyperbaric bupivacaine (CLON/HYPER Group; n = 11) or 2.5 mg of 0.5 percent isobaric bupivacaine (CLON/ISO Group; n = 11) associated with 2.5 µg of sufentanil and 30 µg of clonidine. Pain, evaluated by the Visual Analogue Scale, heart rate, and mean arterial pressure were assessed every 5 minutes during the first 15 minutes, and then every 15 minutes afterwards until delivery. The prevalence of side effects (nausea, vomiting, pruritus, and sedation) was evaluated. The study was terminated whenever the patient needed supplemental epidural analgesia (pain > 3) or upon delivery of the fetus. The Student t test, Chi-square test, Fisher exact test, and two-way ANOVA for repeated measurements were used in the statistical analysis and a p < 0.05 was considered significant. RESULTS: Anthropometric data, duration of analgesia (70.9 ± 32.9 vs. 85.4 ± 39.5), heart rate, and the incidence of pruritus, sedation, nausea, and vomiting were similar in both groups. Mean arterial pressure was significantly lower in the CLON/ISO Group than in the CLON/HYPER Group at 15, 30, and 45 minutes (p < 0.05). CONCLUSIONS: Under the conditions of the present study, the association of a small dose of clonidine (30 µg) with sufentanil caused a higher incidence of hypotension when the isobaric solution of the local anesthetic was used. For all other side effects, both hyperbaric and isobaric solutions...

JUSTIFICATIVA Y OBJETIVOS: La adición de la clonidina subaracnoidea (±-agonista), prolonga la acción analgésica de la combinación sufentanil y bupivacaína isobárica en analgesia combinada para el trabajo de parto Õ. El objetivo de este estudio fue comparar la calidad de analgesia y la prevalencia de los efectos colaterales, después de la adición de clonidina subaracnoidea a la solución anestésica en gestantes durante el parto. MÉTODO: Después de la aprobación de la Comisión de Ética, 22 gestantes en trabajo de parto recibieron aleatoriamente en el espacio subaracnoideo 2,5 mg de bupivacaína hiperbárica 0,5 por ciento (grupo CLON/HIPER; n = 11) o 2,5 mg de bupivacaína isobárica 0,5 por ciento (grupo CLON/ISO; n = 11) en asociación con el sufentanil 2,5 µg y la clonidina 30 µg. El dolor evaluado por la Escala Analógica Visual, la frecuencia cardíaca y la presión arterial promedio, fueron estudiados a cada 5 minutos en los primeros 15 minutos y a continuación, a cada 15 minutos hasta el nacimiento. Fue evaluada la prevalencia de efectos colaterales (náusea, vómito, prurito y sedación). El estudio fue terminado en el momento en que se hizo necesaria la complementación analgésica epidural (dolor > 3 cm) o al nacimiento. El análisis estadístico fue realizado a través de los tests t de Student, Chi-cuadrado, Fisher y ANOVA de dos vías para medidas repetidas, considerando como significativo p < 0,05. RESULTADOS: Los grupos CLON/HIPER y CLON/ISO fueron similares con relación a los datos antropométricos, duración de la analgesia (70,9 ± 32,9 vs. 85,4 ± 39,5), frecuencia cardíaca, incidencia de prurito, sedación, náusea y vómitos. En el grupo CLON/ISO hubo una disminución significativa de la presión arterial promedio con relación al grupo CLON/HIPER en los momentos 15, 30, y 45 minutos (p < 0,05). CONCLUSIONES: En las condiciones estudiadas, la adición de clonidina en baja dosis (30 »g), asociada al sufentanil, determinó una mayor incidencia de...

Efeito da adição de clonidina subaracnóidea à bupivacaína hiperbárica e sufentanil para analgesia de parto / The effect of adding subarachnoid clonidine to hyperbaric bupivacaine and sufentanil during labor analgesia

JUSTIFICATIVA E OBJETIVOS: A adição de clonidina subaracnóidea (um alfa-agonista), prolonga a ação analgésica da combinação do sufentanil e da bupivacaína isobárica em analgesia combinada para o trabalho de parto. O objetivo desse estudo foi comparar a qualidade e a duração de analgesia e a incidência de efeitos colaterais após a adição de clonidina subaracnóidea à bupivacaína hiperbárica e sufentanil em anestesia combinada raqui-peridural para o trabalho de parto. MÉTODO: Foram estudadas 26 gestantes de termo, estado físico ASA I, em trabalho de parto, que receberam aleatoriamente no espaço subaracnóideo: clonidina, sufentanil e bupivacaína (n = 13), denominado Grupo Clon/Sufenta/Bupi, 2,5 mg de bupivacaína hiperbárica a 0,5 por cento associada a 2,5 µg de sufentanil e 30 µg de clonidina; sufentanil e bupivacaína (n = 13), denominado Grupo Sufenta/Bupi, 2,5 mg de bupivacaína hiperbárica a 0,5 por cento associada a 2,5 µg de sufentanil. O estudo foi duplamente encoberto. A dor e os efeitos colaterais (náusea, vômito, prurido, hipotensão arterial e sedação) foram avaliados a cada cinco minutos nos primeiros 15 minutos e, a seguir, a cada 15 minutos até o nascimento. A dor foi avaliada com a escala analógica visual de 0-10 cm (VAS = 0, ausência de dor e 10, dor insuportável), e o estudo foi encerrado no momento em que foi necessária complementação analgésica peridural (dor > 3 cm) ou ao nascimento. A análise estatística foi realizada com os testes t de Student e Exato de Fisher, considerando como significativo p < 0,05. RESULTADOS: As médias de dor nos momentos - 0 min (8,9 ± 1,6/7,6 ± 2,1), 5 min (3,4 ± 2,3/2,3 ± 3,1), 10 min (1,5 ± 2,5/1,4 ± 2,2) e 15 min (0,26 ± 0,8/1,4 ± 2,2) nos grupos Clon/Sufenta/Bupi e Sufenta/Bupi foram semelhantes, respectivamente. Não se observaram diferenças em relação à duração da analgesia (58,8 ± 32 min / 55,4 ± 53 min), ocorrência de prurido (4/13 e 4/12 pacientes), náusea (1/13 e 1/12 pacientes), vômito (1/13 e 0/12 pacientes) e hipotensão arterial (2/13 e 1/12 pacientes) nos grupos Clon/Sufenta/Bupi e Sufenta/Bupi, respectivamente. Não se observou efeito sedativo da clonidina em nenhuma paciente. Uma paciente do grupo Sufenta/Bupi foi excluída do estudo por falha total do bloqueio após 15 minutos...

[The effect of adding subarachnoid clonidine to hyperbaric bupivacaine and sufentanil during labor analgesia.]. / Efeito da adição de clonidina subaracnóidea à bupivacaína hiperbárica e sufentanil para analgesia de parto.

BACKGROUND AND OBJECTIVES: Adding subarachnoid clonidine (an alpha -agonist) prolongs the analgesic effect of the combination of sufentanil and isobaric bupivacaine when combined during labor analgesia. The aim of this study was to compare the quality and duration of the analgesia as well as the incidence of side-effects after the addition of subarachnoid clonidine to hyperbaric bupivacaine and sufentanil in a combined spinal-epidural analgesia during labor. METHODS: Twenty-six patients, physical status ASA I in full-term pregnancy were studied. They randomly received the following in the subarachnoid space: clonidine, sufentanil and bupivacaine (n = 13) - referred to as the Clon/Sufenta/Bupi Group - wherein 2.5 mg of 0.5% hyperbaric bupivacaine was added to 2.5 microg of sufentanil and 30 microg of clonidine; sufentanil and bupivacaine (n = 13) - referred to as the Sufenta/Bupi Group - wherein 2.5 mg of 0.5% hyperbaric bupivacaine was added to 2.5 microg of sufentanil. This was a double-blind study. Evaluations of pain and side effects (nausea, vomiting, itching, low blood pressure and sedation) were conducted every five minutes for the first 15 minutes and after that, every 15 minutes up until the birth of the baby. Pain was evaluated using a visual analogic scale ranging from 0-10 cm (VAS 0 = absence of pain and 10 = unbearable pain). The study was over whenever complementary epidural anasthesia was found necessary (pain > 3 cm) or at the moment of birth. A Student t-test statistical analysis was performed and the results were significant (p < 0.05). RESULTS: The mean pain scores at the times measured were similar for the Clon/Sufenta/Bupi and Sufenta/Bupi Groups respectively: 0 min (8.9 +/- 1.6/ 7.6 +/- 2.1), 5 min (3.4 +/- 2.3/ 2.3 +/- 3.1), 10 min (1.5 +/- 2.5/ 1.4 +/- 2.2) and 15 min (0.26 +/- 0.8/ 1.4 +/- 2.2). No differences between the Clon/Sufenta/Bupi and Sufenta/Bupi Groups, respectively, were observed regarding: the duration of the analgesia (58.8 +/- 32 min / 55.4 +/- 53 min), itching (4/13 and 4/12 patients), nausea (1/13 and 1/12 patients), vomiting (1/13 and 0/12 patients) and low blood pressure (2/13 and 1/12 patients). The sedative effect of clonidine was not observed in any patient. One patient from the Sufenta/Bupi group was eliminated from the study because the anaesthesia failed to take effect after 15 minutues. CONCLUSIONS: Under the conditions observed in the study, adding a low dosage of clonidine when combined with a hyperbaric solution does not prolong the duration of the analgesia, does not improve the quality of the action and does not act as the determining factor for the occurence of low blood pressure or sedation.