The Effect of Glycopyrrolate on the Incidence of Hypotension and Vasopressor Requirement During Spinal Anesthesia for Cesarean Delivery: A Meta-analysis.

BACKGROUND: The objective of this meta-analysis was to determine the efficacy of glycopyrrolate at reducing spinal hypotension during cesarean delivery. METHODS: A literature search was performed to identify randomized controlled trials investigating the effect of glycopyrrolate on spinal-induced hypotension during cesarean delivery. Primary outcomes were intraoperative hypotension and vasopressor requirement (phenylephrine equivalents). Secondary outcomes included heart rate (HR), nausea and vomiting, dry mouth, and Apgar scores. Risk ratios (RRs), and mean differences (MDs) were calculated using random-effects modeling with 95% confidence intervals for primary outcomes and 99% confidence intervals for secondary outcomes. RESULTS: Five randomized controlled trials met our inclusion criteria. A total of 311 patients were included: 153 received glycopyrrolate and 158 placebo. The incidence of spinal-induced hypotension was no different with prophylactic glycopyrrolate compared to control (RR, 0.93 [0.71-1.21]; P = .59), but the total phenylephrine dose required was significantly reduced with glycopyrrolate (MD, -62.64 µg [-107.61 to -17.66 µg]; P = .006). The maximal HR achieved in the glycopyrrolate group was significantly higher compared to controls (MD, 15.85 bpm [5.40-26.31]; P < .0001); however, the incidence of bradycardia was not statistically different. The incidence of intraoperative nausea and vomiting was not different between groups; however, glycopyrrolate increased the risk of dry mouth (RR, 5.15 [1.82-14.57]; P < .0001). Apgar scores at 1 and 5 minutes did not differ between groups. CONCLUSIONS: Prophylactic glycopyrrolate does not reduce the incidence of spinal-induced hypotension but results in a modest reduction in vasopressor requirements while increasing maternal HR.

Parenteral opioid analgesia: Does it still have a role?

Parenteral opioids have been used in labour analgesia for many years, but the ideal opioid in this setting is yet to be found. We review the properties of currently used opioids, their analgesic properties and side effects to mother and foetus. Parenteral opioids can be administered as intermittent boluses or through a patient-controlled intravenous administration system. A wide range of opioid drugs are currently used and provide a variable degree of analgesia. All opioids can cause unwanted maternal side effects such as nausea, vomiting, sedation and respiratory depression. They cross the placenta and have the potential to cause neonatal respiratory depression. Remifentanil patient-controlled intravenous analgesia is becoming increasingly available and popular on some delivery suites. It can provide adequate analgesia and is useful when epidural analgesia is contraindicated. Remifentanil patient-controlled analgesia requires close monitoring in an environment familiar with the technique to avoid maternal hypoxia due to respiratory depression.

El manejo de la intubación traqueal difícil y/o fallida en anestesia obstétrica / Difficult tracheal intubation management and / or failed in obstetric anesthesia

Las nuevas guías, proveen una estructura paso a paso, para el manejo de intubación difícil y fallida en obstetricia. Aunque muchos centros pueden tener sus propias guías, la producción de una directriz nacional, provee ahora una Algoritmo estándar. Tabla 1 en una herramienta de entrenamiento que permite la toma de decisiones y ayudar a determinar si despertar al paciente o continuar con la cirugía. Mensajes claves de estas guías son:• Uso de ventilación con mascarilla, durante inducción de secuencia rápida.• Remoción de la presión cricoidea, durante intubación fallida.• Uso precoz de dispositivos supragloticos en intubación fallida.• Uso de bloqueo neuromuscular profundo previo a definir.