Comparison of terbutaline and atosiban as tocolytic agents in intrauterine repair of myelomeningocele: a retrospective cohort study.

BACKGROUND: Myelomeningocele (MMC) is a neural tube defect disease. Antenatal repair of fetal MMC is an alternative to postnatal repair. Many agents can be used as tocolytics during the in utero fetal repair such as ß2-agonists and oxytocin receptor antagonists, with possible maternal and fetal repercussions. This study aims to compare maternal arterial blood gas analysis between terbutaline or atosiban, as tocolytic agents, during intrauterine MMC repair. METHODS: Retrospective cohort study. Patients were divided into two groups depending on the main tocolytic agent used during intrauterine MMC repair: atosiban (16) or terbutaline (9). Maternal arterial blood gas samples were analyzed on three moments: post induction (baseline, before the start of tocolysis), before extubation, and two hours after the end of the surgery. RESULTS: Twenty-five patients were included and assessed. Before extubation, the terbutaline group showed lower arterial pH (7.347 ± 0.05 vs. 7.396 ± 0.02 for atosiban, p = 0.006) and higher arterial lactate (28.33 ± 12.76 mg.dL-1 vs. 13.06 ± 6.35 mg.dL-1, for atosiban, p = 0.001) levels. CONCLUSIONS: Patients who received terbutaline had more acidosis and higher levels of lactate, compared to those who received atosiban, during intrauterine fetal MMC repair.

Plasmatic catecholamines after neuraxial labour analgesia: A randomised controlled trial comparing epidural versus combined spinal-epidural.

BACKGROUND: Combined spinal-epidural technique (CSE) for labour analgesia has been associated with fetal bradycardia and uterine hypertonia when compared with epidural analgesia (EA), possibly due to a decrease in epinephrine levels following neuraxial anaesthesia. However, there are no recent studies comparing plasmatic catecholamines levels between those two techniques. This study aimed to compare CSE versus EA regarding pre- and post-analgesia catecholamines levels, uterine tone and fetal heart rate. PATIENTS AND METHODS: Randomised clinical trial with 47 labouring patients divided in two groups (CSE and EA). Primary outcome was plasmatic catecholamine measurements before and after neuraxial block. Secondary outcomes were fetal heart rate changes, uterine hypertonia, hypotension episodes, pain relief and fetal outcomes. RESULTS: For CSE group, the median decrease of plasmatic epinephrine was 0 pg/mL [(-) 480-(+) 41] and for norepinephrine was -21 pg/mL [(-) 2507-(+) 94]. For EA group, the median decrease for epinephrine was 0 pg/mL [(-) 326-(+) 15] and for norepinephrine was -5 pg/mL [(-) 190-(+76)]. There were no differences between groups (p = 0.96 and p = 0.63 for epinephrine and norepinephrine, respectively). There were no differences for secondary outcomes. CONCLUSIONS: There was no evidence of a more significant decrease of catecholamines with CSE when compared with EA. Catecholamines decrease theory may not be valid for modern labour analgesia techniques.

Which Model Is Better to Teach How to Perform Tube Thoracostomy: Synthetic, Cadaver, or Animal?

INTRODUCTION: The lack of standardized skill training reported by medical students in performing tube thoracostomies may be associated with higher complications. The ideal training model is yet to be determined. This study sought to evaluate three different models. METHODS: Between 2015 and 2017, 204 last-year medical students of Universidade de São Paulo with no prior training in tube thoracostomy were randomized into three groups: cadaver, pig, and synthetic models. All groups performed 1-d tube thoracostomy hands-on training and a 40-min theoretical class. The knowledge acquisition was measured by a comparison between a theoretical test before and 3 wk after the class, and the skills improvement was evaluated by a comparison between the skills test on the same day of the hands-on training and another after 24 wk (the retention skill test). A questionnaire was submitted to evaluate their satisfaction rate and self-reported confidence, as per a Likert scale. RESULTS: The theoretical post-test score was higher compared to the pretest score in all groups (P < 0.001). The retention skills test in the cadaver and synthetic groups decreased compared to the skills test (P = 0.01 and P = 0.007, respectively). There was no difference between the groups either in the theoretical test or in the skills test. Student satisfaction was higher in the cadaver and pig groups. The confidence perception increased in all groups after the training. CONCLUSIONS: The models used for tube thoracostomy training appear to have a similar impact on skills retention, knowledge acquisition, and confidence. Although the satisfaction rate is lower for the synthetic model, it has no biological risk or ethical issues and is more feasible.