Hiperpirexia maligna / Malignant hyperpyrexia

Se revisa el tema de la hiperpirexia maligna y otros síndromes hipertérmicos. Tras una descripción de la fisiopatología se proponen pautas de diagnóstico, diagnóstico diferencial y tratamiento ante un aumento de la temperatura de un paciente. Dentro de esta entidad es fundamental el diagnóstico precoz y el tratamiento inmediato, el cual puede ser instaurado siguiendo una protocolización estricta, que incluye una distribución de las tareas entre varios componentes del equipo anestesicoquirúrgico, incluyendo la enfermería. La colaboración de varios profesionales es imprescindible. Se destaca la ausencia de seguimiento y apoyo a nivel nacional, y se aporta una dirección de correo electrónico para ayuda (AU)

This article reviews malignant hyperpyrexia and other hyperthermic syndromes. The physiopathology of these syndromes is described and strategies for their diagnosis, differential diagnosis and treatment are proposed. Early diagnosis and immediate treatment are essential. The latter can be initiated by following a strict protocol, which includes the distribution of tasks among the various components of the anesthesiology-surgical care team, including nurses. The collaboration of various professionals is essential. The lack of follow-up and national support is highlighted and an e-mail address for support is provided (AU)

[Efficacy of low-dose oxytocin during elective cesarean section]. / Eficacia de la oxitocina a dosis bajas en cesáreas electivas.

BACKGROUND AND OBJECTIVE: In cesarean section, the optimal dose of oxytocin to reduce the risk of hemorrhage with the least risk of adverse effects has yet to be defined. We studied the effects of using 2 different doses of oxytocin in women undergoing elective cesarean section under spinal anesthesia. The women had had no prior labor. MATERIAL AND METHODS: Randomized multicenter trial enrolling 104 patients classified as ASA 1. Following fetal extraction and coinciding with umbilical cord clamping, a group of 52 women received 1 IU of oxytocin followed by an infusion of 2.5 IU x h(-1); a second group of 52 women received a continuous infusion of 20 IU at a rate of 700 mlU x min(-1) followed by 10 IU x min(-1). We compared uterine contractility (assessed as absent, moderate, satisfactory), postoperative vaginal bleeding (absent, light, moderate, heavy), hemodynamics, and adverse effects after administration of oxytocin and fetal extraction (electrocardiographic abnormalities, nausea, vomiting, discomfort, headache, blushing, trembling, chills, or chest pain). RESULTS: No significant between-group differences in patient, obstetric, or anesthetic variables were detected. Uterine contraction was satisfactory in over 90% of the patients in both groups on initial assessment during surgery. After surgery, vaginal bleeding was absent or light in over 90% of the women. No significant differences in adverse events were detected between groups. CONCLUSIONS: The incidence of obstetric bleeding is not higher when a lower dose of oxytocin is used; the rate of postoperative adverse events also does not increase.

Eficacia de la oxitocina a dosis bajas en cesáreas electivas / Efficacy of low-dose oxytocin during elective cesarean section

Objetivos: La dosis óptima de oxitocina en cesáreas que permita reducir el riesgo de hemorragia con la menor incidencia de efectos adversos derivados de su empleo no está bien definida. Estudiamos diversos parámetros tras la administración de oxitocina a diferentes dosis en cesáreas electivas con anestesia subaracnoidea en pacientes sin trabajo previo de parto. Material y métodos: Estudio de 104 pacientes ASA 1 aleatorizado, descriptivo, observacional y prospectivo multicéntrico. El grupo 1 (n = 52) recibió tras la extracción fetal y coincidiendo con el clampaje del cordón umbilical 1 UI de oxitocina seguida de una perfusión de 2,5 UI.h–1, y el grupo 2 (n = 52) una infusión continua de 20 UI a un ritmo de 700 mUI.min–1 seguido posteriormente a 10 UI.h–1. Se analizó la contractilidad uterina (ausente, moderada, satisfactoria), hemorragia vaginal postoperatoria (ausente, leve, moderada, abundante), comportamiento hemodinámico y efectos secundarios tras administración de oxitocina tras la extracción fetal (alteraciones en el ECG, náuseas, vómitos, malestar general, cefalea, enrojecimiento, temblor, escalofríos o dolor torácico). Resultados: No hubo diferencias significativas entre ambos grupos en las variables antropométricas, obstétricas o anestésicas. Así, la contracción uterina fue satisfactoria en más del 90% de las pacientes desde la primera exploración intraoperatoria en ambos grupos. La hemorragia vaginal postquirúrgica se cuantificó como ausente o leve en más del 90% de las gestantes. Tampoco en la incidencia de efectos adversos de la oxitocina hubo diferencias significativas. Conclusiones: La administración de dosis bajas de oxitocina en la cesárea electiva no se acompaña de una mayor incidencia de hemorragia obstétrica que el uso de dosis mayores, sin influir en la aparición de efectos secundarios(AU)

Background and objective: In cesarean section, the optimal dose of oxytocin to reduce the risk of hemorrhage with the least risk of adverse effects has yet to be defined. We studied the effects of using 2 different doses of oxytocin in women undergoing elective cesarean section under spinal anesthesia. The women had had no prior labor. Material and methods: Randomized multicenter trial enrolling 104 patients classified as ASA 1. Following fetal extraction and coinciding with umbilical cord clamping, a group of 52 women received 1 IU of oxytocin followed by an infusion of 2.5 IU·h-1; a second group of 52 women received a continuous infusion of 20 IU at a rate of 700 mIU·min-1 followed by 10 IU·min-1. We compared uterine contractility (assessed as absent, moderate, satisfactory), postoperative vaginal bleeding (absent, light, moderate, heavy), hemodynamics, and adverse effects after administration of oxytocin and fetal extraction (electrocardiographic abnormalities, nausea, vomiting, discomfort, headache, blushing, trembling, chills, or chest pain). Results: No significant between-group differences in patient, obstetric, or anesthetic variables were detected. Uterine contraction was satisfactory in over 90% of the patients in both groups on initial assessment during surgery. After surgery, vaginal bleeding was absent or light in over 90% of the women. No significant differences in adverse events were detected between groups. Conclusions: The incidence of obstetric bleeding is not higher when a lower dose of oxytocin is used; the rate of postoperative adverse events also does not increase(AU)

Analgesia obstétrica subaracnoidea continua. Una alternativa eficaz a la anestesia epidural / No disponible

No disponible

[Paresthesia and spinal anesthesia for cesarean section: comparison of patient positioning]. / Parestesias y anestesia subaracnoidea en cesáreas: estudio comparativo según la posición de la paciente.

OBJECTIVE: To determine the incidence of paresthesia during lumbar puncture performed with the patient in different positions. MATERIAL AND METHODS: A single-blind prospective study of patients scheduled for elective cesarean section, randomized to 3 groups. In group 1 patients were seated in the direction of the long axis of the table, with heels resting on the table. In group 2 they were seated perpendicular to the long axis of the table, with legs hanging from the table. In group 3 they were in left lateral decubitus position. Lumbar punctures were performed with a 27-gauge Whitacre needle. RESULTS: One hundred sixty-eight patients (56 per group) were enrolled. Paresthesia occurred most often in group 3 (P = .009). We observed no differences in blood pressure after patients moved from decubitus position to the assigned position. Nor did we observe between-group differences in blood pressure according to position taken during puncture. CONCLUSION: Puncture undertaken with the patient seated, heels on the table and knees slightly bent, is associated with a lower incidence of paresthesia than puncture performed with the patient seated, legs hanging from the table. Placing the patient's heels on the table requires hip flexion and leads to anterior displacement of nerve roots in the dural sac. Such displacement would increase the nerve-free zone on the posterior side of the sac, thereby decreasing the likelihood of paresthesia during lumbar puncture. A left lateral decubitus position would increase the likelihood of paresthesia, possibly because the anesthetist may inadvertently not follow the medial line when inserting the needle.

Parestesias y anestesia subaracnoidea en cesáreas: estudio comparativo según la posición de la paciente / Paresthesia and spinal anesthesia for cesarean section: comparison of patient positioning

OBJETIVO: Determinar la incidencia de parestesiasdurante la punción lumbar según la posición adoptadapor el paciente.MATERIAL Y MÉTODO: Estudio simple ciego, prospectivoy aleatorizado en pacientes programadas para cesáreaelectiva distribuidas en 3 grupos. Grupo 1: pacientesentada en la dirección del eje largo de la cama apoyandosus talones sobre la misma; grupo 2: paciente sentadaen dirección perpendicular al eje largo de la cama,con las piernas colgando; y grupo 3: paciente en decúbitolateral izquierdo. Las punciones lumbares se realizaroncon aguja 27-G Whitacre.RESULTADOS: Se incluyeron 168 pacientes (56 por grupo).Las parestesias fueron más frecuentes en el grupo 3(p = 0,009). No objetivamos cambios entre los valores depresión arterial en decúbito y tras adoptar la posición depunción. Tampoco encontramos diferencias entre gruposen la presión arterial según la postura adoptada para realizarla punción.DISCUSIÓN: La punción en sedestación apoyando lostalones sobre la cama, con ligera flexión de rodillas presentamenor número de parestesias que la punción realizadaen sedestación pero con las piernas colgando. Lostalones sobre la cama producen una flexión de la caderacon un desplazamiento de las raíces nerviosas dentro delsaco dural a una posición más anterior. Este desplazamientoaumentaría el área libre de raíces nerviosas en lazona posterior del saco dural disminuyendo la posibilidadde parestesias durante las punciones lumbares. Laposición en decúbito lateral izquierdo aumentaría laposibilidad de parestesias, posiblemente porque la agujase desvía de la línea media de forma inadvertida (AU)

OBJECTIVE: To determine the incidence of paresthesiaduring lumbar puncture performed with the patient indifferent positions.MATERIAL AND METHODS: A single-blind prospectivestudy of patients scheduled for elective cesarean section,randomized to 3 groups. In group 1 patients were seatedin the direction of the long axis of the table, with heelsresting on the table. In group 2 they were seatedperpendicular to the long axis of the table, with legshanging from the table. In group 3 they were in leftlateral decubitus position. Lumbar punctures wereperformed with a 27-gauge Whitacre needle.RESULTS: One hundred sixty-eight patients (56 pergroup) were enrolled. Paresthesia occurred most often ingroup 3 (P = .009). We observed no differences in bloodpressure after patients moved from decubitus position tothe assigned position. Nor did we observe between-groupdifferences in blood pressure according to position takenduring puncture.CONCLUSION: Puncture undertaken with the patientseated, heels on the table and knees slightly bent, isassociated with a lower incidence of paresthesia thanpuncture performed with the patient seated, legs hangingfrom the table. Placing the patient's heels on the tablerequires hip flexion and leads to anterior displacement ofnerve roots in the dural sac. Such displacement wouldincrease the nerve-free zone on the posterior side of thesac, thereby decreasing the likelihood of paresthesiaduring lumbar puncture. A left lateral decubitus positionwould increase the likelihood of paresthesia, possiblybecause the anesthetist may inadvertently not follow themedial line when inserting the needle (AU)

¿Es realmente necesaria y útil la oxigenoterapia suplementaria en lacesárea programada bajo anestesia subaracnoidea? / Is oxygen therapy truly useful and necessary during elective cesarean section under spinal anesthesia?

OBJETIVOS: Analizar el bienestar maternofetal enfunción de la administración o no de oxígeno suplementario.MATERIAL Y MÉTODOS: Estudio prospectivo y aleatorizadode gestantes a término con embarazo controlado,ASA I, sin patologías maternofetales, programadas paracesárea bajo anestesia subaracnoidea, divididas en 2grupos cuya única diferencia metodológica fue la respiraciónde aire ambiente (grupo AA) o la administraciónde oxígeno con mascarilla facial (FiO2 40%) (grupo MF).Valoramos el bienestar neonatal postparto inmediatocon la gasometría del cordón umbilical y el test deApgar.RESULTADOS: Se incluyeron 130 gestantes. Ambos gruposresultaron homogéneos, sin diferencias demográficas,hemodinámicas, en el tiempo incisión uterinaextracciónfetal, peso de los recién nacidos, presencia deanomalías del cordón umbilical, tipo de reanimación delrecién nacido o Apgar al 1º y 5º min. La saturación periféricade oxígeno materna fue mayor (p < 0,001) a partirde los 10 min en el grupo MF. Observamos diferenciasestadísticamente significativas en la sangre arterialumbilical en la pCO2 (51,14 vs 54,33 mm Hg) (p=0,016),bicarbonato (22,19 vs 23,23 mEq.L-1) (p=0,012) y lactato(1,85 vs 1,64 mmol.L-1) (p=0,038) y en la pO2 venosa(25,53 vs 28,13 mm Hg) (p=0,033) en los grupos AA vsMF respectivamente.CONCLUSIONES: En la cesárea bajo anestesia subaracnoideade pacientes sanas, la administración de oxígenosuplementario no se acompaña de diferencias en el estadode bienestar final neonatal (AU)

OBJECTIVE: To analyze maternal and fetal well-beingwith and without the application of oxygen therapy.MATERIAL AND METHODS: Randomized trial of full-termparturients who had received prenatal care duringpregnancy. The women were healthy and classified as ASA1.They were scheduled for delivery by cesarean sectionunder spinal anesthesia and randomized to 2 groups tobreathe room air or air providing an inspired oxygenfraction of 40% through a face mask. We assessed thewell-being of the neonate immediately after birth with theApgar test and by measuring umbilical cord blood gases.RESULTS: One hundred thirty women were enrolled.Both groups were similar, with no differences indemographic or hemodynamic variables, time fromuterine incision to fetal extraction, neonatal birth weight,presence of umbilical cord abnormalities, type ofresuscitation required by the neonate, or Apgar score inthe first or fifth minute. Oxygen saturation in maternalblood by pulse oximetry was higher after 10 minutes inthe group of women who received supplemental oxygenthrough face masks. We also observed significantdifferences in umbilical cord arterial blood between theroom air and supplemental oxygen groups, respectively,as follows: PaCO2, 51.14 mm Hg vs 54.33 mm Hg(P=.016); bicarbonate, 22.19 mEq·L-1 vs 23.23 mEq·L-1(P=.012); lactate, 1.85 mmol·L-1 vs 1.64 mmol·L-1 (P=.038).The PO2 in venous blood also differed significantly: 25.53mm Hg vs 28.13 mm Hg, respectively (P=0.33).CONCLUSIONS: Breathing supplemental oxygen or notduring elective cesarean delivery of healthy parturientsunder spinal anesthesia does not have a significant effecton neonatal well-being (AU)

[Continuous subarachnoid analgesia and anesthesia for labor and cesarean section in a patient who had previously undergone surgery for ependymoma]. / Analgoanestesia subaracnoidea continua para trabajo de parto y cesárea en paciente intervenida de ependimoma.

We report the case of a 38-year-old primipara who had undergone surgery 2 years earlier for an intradural ependymoma at L2-L3 and who was currently asymptomatic. A combined epidural-subarachnoid block was performed for analgesia during labor but this technique was only effective for the first 2 hours. When analgesia via epidural cannula was no longer adequate, it was decided to perform a continuous subarachnoid block. Later, the fetus's head was seen to be too large to fit through the pelvis; for cesarean section, the mother was administered fractionated doses of local anesthetic via the subarachnoid cannula until analgesia reached T4. The patient did not develop postdural puncture headache. Continuous subarachnoid anesthesia may be considered the technique of choice where the patient has a history of spinal surgery.

[Air embolism during elective cesarean section, and uterine atony due to fetal macrosomia]. / Embolia aérea durante cesáirea electiva y atonía uterina por feto macrosómico.

We report the case of a paradoxical air embolism during a scheduled cesarean section for fetal macrosomia (7.010 kg) in a 38-year-old woman with a history of gestational diabetes and preeclampsia. Spinal anesthesia was satisfactory and well tolerated. After approximately 30 minutes (coinciding with uterine exteriorization), the patient presented a sudden episode of dyspnea, confusion, hypotension, and ST segment depression. The episode lasted approximately 10 minutes and resolved spontaneously with no sequelae. Neurological status and the electrocardiogram were normal at the end of surgery and no postoperative lesions were observed. In the immediate postoperative period, the patient presented a massive hemorrhage due to uterine atony. Echocardiography revealed a patent foramen ovale. The clinical signs in this patient are highly suggestive of a paradoxical cerebral and coronary air embolism.

Analgoanestesia subaracnoidea continua para trabajo de partoy cesárea en paciente intervenida de ependimoma / Continuous subarachnoid analgesia and anesthesia for labor and cesarean section in a patient who had previously undergone surgery for ependymoma

Presentamos el caso de una primigesta de 38 años deedad, entre cuyos antecedentes personales destacabahaber sido intervenida dos años antes de ependimomaintradural a nivel de L2-L3 y en la actualidad se encontrabaasintomática.Se realizó un bloqueo combinado epidural –subaracnoideopara analgesia de parto, que sólo fue eficazdurante las dos primeras horas ya que transcurrido estetiempo, la analgesia por catéter epidural no resultó adecuada,por lo que se optó por realizar un bloqueo subaracnoideocontinuo. Posteriormente fue necesario realizaruna cesárea por una desproporción pélvico– cefálicaadministrándose dosis fraccionadas de anestésico localpor el catéter subaracnoideo hasta alcanzar un nivelanalgésico en las metámeras correspondientes a T4. Lapaciente no refirió cefalea postpunción dural. La anestesiasubaracnoidea continua para cesárea puede ser consideradauna técnica de elección cuando existe el antecedentede una cirugía de raquis (AU)

We report the case of a 38-year-old primipara whohad undergone surgery 2 years earlier for an intraduralependymoma at L2-L3 and who was currentlyasymptomatic. A combined epidural-subarachnoid blockwas performed for analgesia during labor but thistechnique was only effective for the first 2 hours. Whenanalgesia via epidural cannula was no longer adequate,it was decided to perform a continuous subarachnoidblock. Later, the fetus’s head was seen to be too large tofit through the pelvis; for cesarean section, the motherwas administered fractionated doses of local anestheticvia the subarachnoid cannula until analgesia reachedT4. The patient did not develop postdural punctureheadache. Continuous subarachnoid anesthesia may beconsidered the technique of choice where the patient hasa history of spinal surgery (AU)

Embolia aérea durante cesárea electiva y atonía uterinapor feto macrosómico / Air embolism during elective cesarean section, and uterine atony due to fetal macrosomia

Presentamos el caso de una embolia aérea paradójicaocurrida durante una cesárea programada por macrosomíafetal (7,010 kg) en una paciente de 38 años con antecedentesde diabetes gestacional y preeclampsia. Se realizóuna anestesia subaracnoidea satisfactoria y bientolerada. Aproximadamente a los 30 minutos, coincidiendocon maniobras de exteriorización uterina, lapaciente presentó un episodio brusco de disnea, obnubilación,hipotensión y descenso del segmento ST. Esteevento duró 10 min aproximadamente, resolviéndoseespontáneamente y sin secuelas. El estado neurológico yel trazado electrocardiográfico fueron normales al finalizarla cirugía, sin objetivar lesión cardiaca postoperatoria.En el postoperatorio inmediato la paciente presentóuna hemorragia masiva por atonía uterina. El estudioecocardiográfico reveló la presencia de un foramen ovalpermeable. La clínica sucedida en esta paciente es altamentesugestiva de embolia aérea paradójica cerebral y coronaria (AU)

We report the case of a paradoxical air embolismduring a scheduled cesarean section for fetalmacrosomia (7.010 kg) in a 38-year-old woman with ahistory of gestational diabetes and preeclampsia. Spinalanesthesia was satisfactory and well tolerated. Afterapproximately 30 minutes (coinciding with uterineexteriorization), the patient presented a sudden episodeof dyspnea, confusion, hypotension, and ST segmentdepression. The episode lasted approximately 10 minutesand resolved spontaneously with no sequelae.Neurological status and the electrocardiogram werenormal at the end of surgery and no postoperativelesions were observed. In the immediate postoperativeperiod, the patient presented a massive hemorrhage dueto uterine atony. Echocardiography revealed a patentforamen ovale. The clinical signs in this patient arehighly suggestive of a paradoxical cerebral and coronaryair embolism (AU)

[Remifentanil bolus for cesarean section in high-risk patients: study of 12 cases]. / Uso del remifentanilo en bolus en la cesárea de la paciente de alto riesgo: estudio sobre 12 casos.

OBJECTIVES: To evaluate the utility and safety of remifentanil for hemodynamic control during cesarean section in high-risk patients ineligible for spinal anesthesia. METHODS: One minute before induction we injected a bolus of 1 microg x kg(-1) of remifentanil, followed by propofol (2.5 mg x kg(-1)), succinylcholine (1 mg x kg(-1)), cisatracurium, sevoflurane in oxygen and nitrous oxide, and fentanyl (5 microg x kg(-1)) after clamping the umbilical cord. We recorded maternal hemodynamic variables, pulse oximetry, capnography, bispectral index, and presence of muscular rigidity. In the neonate we assessed fetal wellbeing, weight, and requirement for naloxone. Hemodynamic stability was defined as no more than 15% variation in arterial pressure with respect to baseline. RESULTS: Twelve patients undergoing surgery because of placenta abruptio, subarachnoid hemorrhage, HELLP syndrome, or preeclampsia were enrolled. Hemodynamic variables were consistently stable during surgery in all patients. No cases of neonatal rigidity were noted and there was no need for naloxone. The mean Apgar score was 6.42 (1.5) at 1 minute and 8.42 (0.9) at 5 minutes. CONCLUSION: Bolus injection of 1 microg x kg(-1) of remifentanil may be useful for maintaining maternal hemodynamic stability in high-risk obstetric cases. Given the risk of neonatal depression, this resource should be used selectively and the means for neonatal resuscitation should be available.

[Experience with uterine artery embolization in the treatment of massive postpartum hemorrhage]. / Experiencia con la embolización arterial en el tratamiento de la hemorragia masiva obstétrica.

OBJECTIVE: To analyze our experience with uterine artery embolization in the management of massive hemorrhage in obstetric patients. PATIENTS AND METHODS: This observational, retrospective study analyzed all deliveries requiring a blood transfusion that were performed in the maternity unit of Hospital Universitario La Paz between January 1, 2000 and December 31, 2005. RESULTS: A total of 57,835 deliveries were performed with an incidence of postpartum hemorrhage of 0.7% (406 episodes). Uterine artery embolization was performed on 51 patients and 45 patients underwent obstetric hysterectomy. Both procedures were performed on 11 patients. Ten of the patients who underwent obstetric hysterectomy subsequently required uterine artery embolization, whereas only 1 patient required an obstetric hysterectomy following embolization because the hemorrhage was not resolved. The mean consumption of blood products for patients who underwent obstetric hysterectomy was twice that for patients who underwent uterine artery embolization. There were no complications secondary to embolization. CONCLUSIONS: Uterine artery embolization is a safe and effective procedure for managing massive postpartum hemorrhage.

Uso del remifentanilo en bolus en la cesárea de la paciente de altoriesgo: Estudio sobre 12 casos / Remifentanil bolus for cesarean section in high-risk patients: study of 12 cases

OBJETIVOS: Evaluar la utilidad y seguridad del remifentanilopara el control hemodinámico en cesáreas de pacientes de alto riesgo no susceptibles de anestesia espinal.MÉTODOS: Un minuto antes de la inducción administramos un bolo de 1 μg kg-1 de remifentanilo, después,propofol (2,5 mg kg-1), succinilcolina (1 mg kg-1), cisatracurio, sevoflurano-O2 - N2O y 5 μg kg-1 de fentanilo trasla ligadura del cordón. Registramos los valores hemodinámicos maternos, pulsioximetría, capnografía, índicebiespectral, presencia de rigidez muscular. En el neonatovaloramos el bienestar fetal, peso y necesidad de naloxona.Consideramos estabilidad hemodinámica cuando la presión arterial no variaba más del 15% respecto al basal.RESULTADOS: Incluimos 12 pacientes con indicación quirúrgica por abruptio placentae, hemorragia subaracnoidea,síndrome HELLP y preeclampsia. Observamos resultados concordantes con estabilidad hemodinámicaen todas las pacientes durante la cirugía. Ningún neonato presentó rigidez ni necesitó naloxona. El test de Apgaral minuto fue 6,42±1,5 y 8,42±0,9 a los 5 min.CONCLUSIÓN: El remifentanilo en bolo de 1 μg kg-1 puede ser útil en el control hemodinámico materno de lapaciente obstétrica de alto riesgo. Ante el riesgo de depresión neonatal, es conveniente seleccionar los casosdonde se utilice, y disponer de medios de reanimación neonatal (AU)

OBJECTIVES: To evaluate the utility and safety of remifentanil for hemodynamic control during cesarean section in high-risk patients ineligible for spinal anesthesia.METHODS: One minute before induction we injected a bolus of 1 μg·kg-1 of remifentanil, followed by propofol(2.5 mg·kg-1), succinylcholine (1 mg·kg-1), cisatracurium, sevoflurane in oxygen and nitrous oxide, and fentanyl (5μg·kg-1) after clamping the umbilical cord. We recorded maternal hemodynamic variables, pulse oximetry,capnography, bispectral index, and presence of muscular rigidity. In the neonate we assessed fetal wellbeing,weight, and requirement for naloxone.Hemodynamic stability was defined as no more than 15% variation in arterial pressure with respect tobaseline.RESULTS: Twelve patients undergoing surgery because of placenta abruptio, subarachnoid hemorrhage, HELLPsyndrome, or preeclampsia were enrolled. Hemodynamic variables were consistently stable during surgery in allpatients. No cases of neonatal rigidity were noted and there was no need for naloxone. The mean Apgar scorewas 6.42 (1.5) at 1 minute and 8.42 (0.9) at 5 minutes.CONCLUSION: Bolus injection of 1 μg·kg-1 of remifentanil may be useful for maintaining maternal hemodynamicstability in high-risk obstetric cases. Given the risk of neonatal depression, this resource should be usedselectively and the means for neonatal resuscitation should be available (AU)

Experiencia con la embolización arterial en el tratamiento de la hemorragia masiva obstétrica / Experience with uterine artery embolization in the treatment of massive postpartum hemorrhage

OBJETIVO: Analizar la experiencia de la embolizaciónarterial en el manejo de la hemorragia masiva en lapaciente obstétrica.PACIENTES Y MÉTODOS: Estudio retrospectivo y observacional en el que se analizaron todos los partos, que requirieron transfusión sanguínea, realizados en lamaternidad del Hospital Universitario La Paz durante elperiodo comprendido entre el 1 enero del 2000 y el 31 dediciembre del 2005.RESULTADOS: Se realizaron 57.835 partos, siendo laincidencia de hemorragia obstétrica del 0,7% (406 episodios). A 51 pacientes se les realizó una embolización arterial y a 45 se les practicó una histerectomía obstétrica. En 11 pacientes se realizaron ambos procedimientos. Diez de las pacientes a las que se les realizó una histerectomía obstétrica precisaron posteriormente una embolización arterial, mientras que sólo una paciente embolizada precisó en último término una histerectomía obstétrica por no resolverse el cuadro hemorrágico. La media de consumo de hemoderivados fue del doble en la histerectomía obstétrica respecto a las pacientes embolizadas. No se evidenciaron complicaciones secundarias a la embolización arterial.CONCLUSIONES: La embolización arterial es un procedimiento seguro y eficaz para el manejo de la hemorragia masiva obstétrica

OBJECTIVE: To analyze our experience with uterineartery embolization in the management of massivehemorrhage in obstetric patients.PATIENTS AND METHODS: This observational, retrospectivestudy analyzed all deliveries requiring a bloodtransfusion that were performed in the maternity unit ofHospital Universitario La Paz between January 1, 2000and December 31, 2005.RESULTS: A total of 57 835 deliveries were performedwith an incidence of postpartum hemorrhage of 0.7% (406episodes). Uterine artery embolization was performed on 51 patients and 45 patients underwent obstetric hysterectomy. Both procedures were performed on 11 patients. Ten of the patients who underwent obstetric hysterectomy subsequently required uterine artery embolization, whereas only 1 patient required an obstetric hysterectomy following embolization because the hemorrhage was not resolved. The mean consumption of blood products for patients who underwent obstetric hysterectomy was twice that for patients who underwent uterine artery embolization. There were no complications secondary to embolization.CONCLUSIONS: Uterine artery embolization is a safeand effective procedure for managing massive postpartumhemorrhage