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1.
Anesth Analg ; 127(3): 706-713, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29505447

RESUMO

BACKGROUND: Autologous transfusion of intraoperative cell salvage blood may be a potential method to decrease the need for allogeneic packed red blood cell transfusions after cesarean delivery, although there are limited data on the benefits of this method. This study evaluated the implementation of targeted intraoperative cell salvage during cesarean delivery in women at increased risk for hemorrhage at the Women's and Children's Hospital in Ningbo, China. METHODS: All women who underwent cesarean delivery >28 weeks of gestation were included in the study. The period before intraoperative cell collection (October 1, 2010, to August 31, 2012, n = 11,322) was compared with the postimplementation period (September 1, 2012, to June 30, 2015, n = 17,456) using an interrupted time series analysis. In the postimplementation period, women suspected to be at increased risk of the need for a blood transfusion (1604, 9.2%) underwent intraoperative cell salvage collection. The primary outcomes were the monthly rate of allogeneic packed red blood cell use and the incidence of clinical manifestation of acute blood transfusion reactions. RESULTS: The mean (standard deviation) estimated monthly allogeneic packed blood cell transfusion rate at the end of the 57-month study was 2.2% ± 0.7% with the implementation compared with 2.7% ± 0.9% without, difference -0.5%, 95% CI, -1.4% to 0.3%; P = .22. The mean number of allogeneic units transfused per patient was 4.1 ± 0.4 units with implementation and 3.9 ± 0.9 units without, difference 0.2, 95% CI, -1.7 to 1.1 units; P = .69. Intraoperative cell salvage blood was reinfused in 757 (47%) and wasted in 847 (53%) cases. The monthly intraoperative allogeneic packed red blood cells use rate was lower after implementation (difference -0.7%, 95% CI, -0.1% to -1.4%; P = .03); however, the monthly postpartum allogeneic packed red blood cell use rate was unchanged (difference -0.2%, 95% CI, -0.4% to 0.7%; P = .56). The clinical manifestation of acute blood transfusion reactions rate was unchanged (difference -2%, 99% CI, -9% to 5%; P = .55) between the periods. CONCLUSIONS: Our findings suggest that targeted intraoperative cell salvage in women undergoing cesarean delivery was associated with less allogeneic blood exposure in the operating room, but not in the postoperative period. Intraoperative cell salvage in targeted cesarean deliveries was not associated with a lesser allogeneic red blood cell exposure over the hospital admission period. The lack of adverse events associated with intraoperative cell salvage supports the safety of intraoperative cell salvage in cesarean delivery.


Assuntos
Transfusão de Sangue Autóloga/métodos , Cesárea/métodos , Transfusão de Eritrócitos/métodos , Maternidades , Recuperação de Sangue Operatório/métodos , Adulto , Cesárea/efeitos adversos , China/epidemiologia , Estudos de Coortes , Feminino , Humanos , Recém-Nascido , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/prevenção & controle , Gravidez
2.
Anesth Analg ; 122(6): 1931-8, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-27195636

RESUMO

The availability of labor analgesia is highly variable in the People's Republic of China. There are widespread misconceptions, by both parturients and health care providers, that labor epidural analgesia is harmful to mother and baby. Meanwhile, China has one of the highest cesarean delivery rates in the world, exceeding 50%. The goal of the nongovernmental No Pain Labor & Delivery (NPLD) is to facilitate sustainable increases in vaginal delivery rates by increasing access to safe neuraxial labor analgesia, thereby decreasing the cesarean delivery rate. NPLD was launched in 2008 with the stated goal of improving labor outcome in China by increasing the absolute labor epidural analgesia rate by 10%. NPLD established 10 training centers over a 10-year period. We hypothesized that increased availability of labor analgesia would result in reduced requests for cesarean delivery and better labor outcomes for mother and baby. Multidisciplinary teams of Western clinicians and support staff traveled to China for 8 to 10 days once a year. The approach involved establishing 24/7 obstetric anesthesia coverage in Chinese hospitals through education and modeling multidisciplinary approaches, including problem-based learning discussions, bedside teaching, daily debriefings, simulation training drills, and weekend conferences. As of November 2015, NPLD has engaged with 31 hospitals. At 24 of these sites, 24/7 obstetric anesthesia coverage has been established and labor epidural analgesia rates have exceeded 50%. Lower rates of cesarean delivery, episiotomy, postpartum blood transfusion, and better neonatal outcomes were documented in 3 impact studies comprising approximately 55,000 deliveries. Changes in practice guidelines, medical policy, and billing codes have been implemented in conjunction with the modernization of perinatal practice that has occurred concurrently in China since the first NPLD trip in 2008.


Assuntos
Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Prestação Integrada de Cuidados de Saúde , Parto Obstétrico/métodos , Saúde Global , Dor do Parto/terapia , Plantão Médico , Analgesia Epidural/efeitos adversos , Analgesia Obstétrica/efeitos adversos , Cesárea , China , Competência Clínica , Parto Obstétrico/efeitos adversos , Educação Médica Continuada , Procedimentos Cirúrgicos Eletivos , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Capacitação em Serviço , Dor do Parto/diagnóstico , Dor do Parto/fisiopatologia , Equipe de Assistência ao Paciente , Educação de Pacientes como Assunto , Gravidez , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
3.
Anesth Analg ; 121(2): 465-8, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26197375

RESUMO

Intraoperative cell salvage is a strategy to decrease the need for allogeneic blood transfusion. Traditionally, cell salvage has been avoided in the obstetric population because of the perceived risk of amniotic fluid embolism or induction of maternal alloimmunization. With advances in cell salvage technology, the risks of cell salvage in the obstetric population parallel those in the general population. Levels of fetal squamous cells in salvaged blood are comparable to those in maternal venous blood at the time of placental separation. No definite cases of amniotic fluid embolism have been reported and appear unlikely with modern equipment. Cell salvage is cost-effective in patients with predictably high rates of transfusion, such as parturients with abnormal placentation.


Assuntos
Transfusão de Sangue Autóloga , Cesárea/efeitos adversos , Obstetrícia/métodos , Recuperação de Sangue Operatório , Complicações na Gravidez/terapia , Transfusão de Sangue Autóloga/efeitos adversos , Embolia Amniótica/etiologia , Feminino , Humanos , Recuperação de Sangue Operatório/efeitos adversos , Doenças Placentárias/etiologia , Doenças Placentárias/terapia , Hemorragia Pós-Parto/etiologia , Hemorragia Pós-Parto/terapia , Gravidez , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/etiologia , Fatores de Risco , Resultado do Tratamento
5.
Anesth Analg ; 101(3): 876-881, 2005 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-16116007

RESUMO

Women undergoing postoperative postpartum tubal ligation (PPTL) often experience considerable pain. We hypothesized that epidural morphine, as part of a multi-modal analgesic regimen, would decrease postoperative pain and the need for systemic analgesia after PPTL. In a double-blinded study, patients were randomized to receive epidural saline or morphine 2 mg, 3 mg, or 4 mg after epidural anesthesia for PPTL. Postoperatively, ibuprofen 600 mg was administered every 6 h and patients could request acetaminophen 325 mg/hydrocodone 10 mg. The primary outcome variable was time to first request for supplemental analgesia. Verbal rating scores for pain and the incidence and severity of side effects were recorded for 24 h. Morphine group subjects requested supplemental analgesia later and received fewer doses compared with the saline group subjects. Peak cramping and incisional verbal rating scores for pain and the area under the verbal rating scores for pain x time curve for cramping pain were less after epidural morphine compared with saline, but there were no differences among morphine groups. Nausea, vomiting, and pruritus occurred more often in all morphine groups and subjects who received morphine 4 mg required treatment for these side effects more frequently than the saline or morphine 2 mg groups. In conclusion, epidural morphine 2 mg as part of a multi-modal analgesic regimen improved analgesia and decreased the need for supplemental analgesics after PPTL. The need to treat side effects with morphine 2 mg was not increased compared to a regimen of oral acetaminophen/opioid/nonsteroidal antiinflammatory analgesics.


Assuntos
Analgesia Epidural , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Morfina/administração & dosagem , Morfina/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Esterilização Tubária , Acetaminofen/administração & dosagem , Acetaminofen/efeitos adversos , Acetaminofen/uso terapêutico , Administração Oral , Adulto , Analgésicos não Narcóticos/administração & dosagem , Analgésicos não Narcóticos/efeitos adversos , Analgésicos não Narcóticos/uso terapêutico , Analgésicos Opioides/efeitos adversos , Anti-Inflamatórios não Esteroides/administração & dosagem , Anti-Inflamatórios não Esteroides/efeitos adversos , Anti-Inflamatórios não Esteroides/uso terapêutico , Método Duplo-Cego , Feminino , Humanos , Hidrocodona/administração & dosagem , Hidrocodona/efeitos adversos , Hidrocodona/uso terapêutico , Ibuprofeno/administração & dosagem , Ibuprofeno/efeitos adversos , Ibuprofeno/uso terapêutico , Morfina/efeitos adversos , Medição da Dor/efeitos dos fármacos , Náusea e Vômito Pós-Operatórios/epidemiologia , Medicação Pré-Anestésica , Prurido/induzido quimicamente , Prurido/epidemiologia , Mecânica Respiratória/efeitos dos fármacos , Mecânica Respiratória/fisiologia
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