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1.
Anesth Analg ; 132(4): 1138-1145, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33617181

RESUMO

BACKGROUND: Epidural block are often used for analgesia after open nephrectomy surgery. Subcostal anterior quadratus lumborum block may be an alternative. We therefore tested the hypothesis that the continuous subcostal anterior quadratus lumborum block is noninferior to epidural block for analgesia in patients having open partial nephrectomies. METHODS: Adults having open partial nephrectomies were randomly allocated to epidural or unilateral subcostal anterior quadratus lumborum block. The joint primary outcomes were opioid consumption measured in morphine equivalents and pain measured on a numeric rating scale (0-10) from postanesthesia care unit (PACU) until 72 hours after surgery. The noninferiority deltas were 30% for opioid consumption and 1 point on a 0-10 scale for pain. Secondary outcomes included patient global assessment of pain management on the third postoperative day, the number of antiemetic medication doses through the third postoperative day, duration of PACU stay, and postoperative duration of hospitalization. RESULTS: Twenty-six patients were randomized to anterior quadratus lumborum block and 29 to epidural analgesia. Neither pain scores nor opioid consumption in the quadratus lumborum patients were noninferior to epidural analgesia. At 72 hours, mean ± standard deviation pain scores in subcoastal anterior quadratus lumborum block and epidural group were 4.7 ± 1.8 and 4.1 ± 1.7, with an estimated difference in pain scores of 0.62 (95% confidence interval [CI], 0.74-1.99; noninferiority P = .21). The median [Q1, Q3] opioid consumption was more than doubled in quadratus lumborum patients at 70 mg [43, 125] versus 30 mg [18, 75] in the epidural group with an estimated ratio of geometric means of 1.69 (95% CI, 0.66-4.33; noninferiority P = .80). Patient global assessment and duration of PACU and hospital stays did not differ significantly in the 2 groups. CONCLUSIONS: We were unable to show that subcostal anterior quadratus lumborum block are noninferior to epidural analgesia in terms of pain scores and opioid consumption for open partial nephrectomies. Effectiveness of novel blocks should be rigorously tested in specific surgical setting before widespread adoption.


Assuntos
Analgesia Epidural , Nefrectomia , Bloqueio Nervoso , Dor Pós-Operatória/prevenção & controle , Idoso , Analgesia Epidural/efeitos adversos , Analgésicos Opioides/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nefrectomia/efeitos adversos , Bloqueio Nervoso/efeitos adversos , Ohio , Medição da Dor , Limiar da Dor/efeitos dos fármacos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
2.
Zhonghua Fu Chan Ke Za Zhi ; 55(7): 457-464, 2020 Jul 25.
Artigo em Chinês | MEDLINE | ID: mdl-32842249

RESUMO

Objective: To evaluate the effect of dual-tube epidural segmental injection of lidocaine analgesia on the delivery outcome and maternal and infant complications of persistent posterior occipital position postpartum or lateral occipital position postpartum patients with protracted active phase. Methods: The full and single-term primiparas (n=216, 37 to 42 weeks gestation, 22 to 35 years) diagnosed as persistent posterior or lateral occipital position during the active period were selected from the Department of Obstetrics of Qingdao Municipal Hospital from January 2015 to October 2019. The subjects were randomly assigned into two groups: double-tube epidural block group (n=108) and single-tube epidural block group (n=108), 1% lidocaine was used for epidural analgesia respectively under ultrasound guidance. Senior midwife or obstetricians implement new partogram, and guide women to perform position management, and push or rotate the fetal head in a timely manner. Observation indicators: general condition, the use of non-pharmacological analgesic measures, analgesia related conditions and pain visual analogue scale (VAS) score, delivery-related indicator, cesarean section indication, anesthesia-related indicator, maternal and child complications. Results: (1) General condition: the age, weight, height, gestational age, the ratio of persistent lateral or posterior occipital position, cephalic score, and neonatal birth weight between the two groups of women were not statistically significant (all P>0.05). (2) The use of non-pharmacological analgesic measures: the women's Lamaze breathing method, Doula delivery companionship, percutaneous electrical stimulation, and other measures between two groups were compared, and there were not significant differences (all P>0.05). (3) Analgesia related conditions and VAS scores of women undergoing vaginal delivery: compared with the single-tube epidural block group (n=40), the second-partum time of the women in the double-tube epidural block group (n=59) was significantly shortened [(124±44) vs (86±33) minutes, P<0.01]; after 30 minutes of analgesia (4.4±0.5 vs 0.9±0.5, P<0.01), during forced labor in the second stage of labor (5.7±0.6 vs 1.3±0.4, P<0.01), the VAS scores of pain were also significantly reduced (P<0.01). (4) Labor-related indicators: compared with the single-tube epidural block group, the natural delivery rate (21.3% vs 49.1%) and the delivery experience satisfaction rate (51.9% vs 98.1%) of women in the double-tube epidural block group were significantly increased (all P<0.01), cesarean section rate (63.0% vs 45.4%), instrument assisted rate (15.7% vs 5.6%) decreased significantly (all P<0.05). (5) Cesarean section indications: compared with the single-tube epidural block group, the cesarean section rate caused by prolonged labor or protracted active phase of women in the double-tube epidural block group was significantly reduced (38.0% vs 22.2%; P<0.05), and the fetal distress, intrauterine infection, and social factors caused by cesarean section between the two groups were compared, while the differences were not statistically significant (all P>0.05).(6) Anesthesia related indexes: the block planes of the maternal upper tube administration in the double-tube epidural block group were mostly T7, T8, T9-L2 and L3,While,the block planes in the single-tube epidural block group were mostly T10, T11-S1, S2, S3, and the modified Bromage score were all 0. (7) Maternal and child complications: compared with the single-tube epidural block group, the postpartum hemorrhage rate (18.5% vs 7.4%), the perineal lateral cut rate (20.4% vs 5.6%), the neonatal asphyxia rate (12.0% vs 3.7%), ICU rate of transferred neonates (13.9% vs 4.6%) in the double-tube epidural block group were significantly reduced (all P<0.05). Soft birth canal injury rate, puerperal disease rate and neonatal birth rate between two groups were compared, and there were not statistically significant differences (all P>0.05). Conclusion: Dual-tube epidural segmental injection of lidocaine analgesia could increase the natural delivery rate of women with posterior occipital or lateral occipital position with active stagnation, reduce the rate of cesarean section and the rate of transvaginal instruments, and reduce the complications of mother and child.


Assuntos
Analgesia Epidural/métodos , Analgesia Epidural/estatística & dados numéricos , Analgesia Obstétrica/métodos , Analgesia Obstétrica/estatística & dados numéricos , Anestesia Epidural/métodos , Cesárea/estatística & dados numéricos , Parto Obstétrico/estatística & dados numéricos , Trabalho de Parto/efeitos dos fármacos , Lidocaína/administração & dosagem , Adulto , Analgesia Epidural/efeitos adversos , Analgesia Obstétrica/efeitos adversos , Feminino , Humanos , Recém-Nascido , Dor , Gravidez , Resultado da Gravidez , Resultado do Tratamento
3.
PLoS One ; 15(6): e0234353, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32530935

RESUMO

There are inconsistent results regarding the efficacy and safety of intermittent epidural bolus (IPB) versus continuous epidural infusions (CPI) for labor analgesia. This study used a meta-analytic approach to assess the safety and treatment efficacy of IPB versus CPI for labor analgesia based on randomized controlled trials (RCTs). Four electronic databases were used to identify eligible RCTs. Pooled effect estimates at 95% confidence intervals (CIs) were calculated using a random-effects model. Twenty-two RCTs with 2,573 parturients were selected for final analysis. The findings revealed no significant differences between IPB and CPI for the incidences of cesarean and instrumental delivery. IPB was shown to be associated with shorter total duration of labor [weighted mean difference (WMD): -21.46; 95% CI: -25.07 to -17.85; P < 0.001], duration of the first of stage of labor (WMD: -13.41; 95% CI: -21.01 to -5.81; P = 0.001), and duration of the second stage of labor (WMD: -4.98; 95% CI: -9.32 to -0.63; P = 0.025). Furthermore, IPB significantly reduced the incidences of required anesthetic interventions compared with CPI [relative risk (RR): 0.61; 95% CI: 0.39-0.95; P = 0.030], whereas there was no significant difference between IPB and CPI for the time required in the first anesthetic intervention (WMD: 7.73; 95% CI: -33.68-49.15; P = 0.714). The local anesthetic IPB (bupivacaine equivalents) was associated with lower milligrams per hour of local anesthetic (WMD: -0.89; 95% CI: -1.41 to -0.36; P = 0.001) and better maternal satisfaction (WMD: 8.76; 95% CI: 4.18-13.35; P < 0.001). There were no significant differences between IPB and CPI for the risk of adverse events. This study found that parturients with IPB have short total duration of labor and duration of the first and second stage of labor, reduced requirements for additional anesthetic interventions, and improved maternal satisfaction.


Assuntos
Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Dor do Parto/tratamento farmacológico , Adulto , Analgesia Epidural/efeitos adversos , Analgesia Obstétrica/efeitos adversos , Analgésicos/administração & dosagem , Bupivacaína/administração & dosagem , Parto Obstétrico/métodos , Esquema de Medicação , Feminino , Humanos , Infusão Espinal/métodos , Injeções Espinhais/métodos , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Segurança , Resultado do Tratamento
4.
Int J Gynaecol Obstet ; 150(1): 92-97, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32364638

RESUMO

OBJECTIVE: To test for an association between blood loss and time until pushing (TUP) after full cervical dilation in nulliparous women with epidural analgesia. METHODS: A prospective cohort study was performed at the University Hospital of Zurich between October 2015 and November 2016. Included were 228 nulliparous women with singleton pregnancy, planned vaginal delivery after 36 completed weeks of gestation, epidural analgesia, and guided active pushing. TUP was defined as the interval between full cervical dilation and initiation of active pushing. The primary outcome measure was blood loss, assessed by the postpartum decrease in hemoglobin (ΔHb), estimated blood loss, and rate of ΔHb ≥30 g/L. Associations between TUP and primary and secondary maternal and neonatal delivery outcomes were assessed using Spearman correlation, Mann-Whitney U test, Kruskal-Wallis test, or Fisher exact test, as appropriate. RESULTS: Longer TUP correlated significantly with increased ΔHb (ρ=0.142, P=0.033) and higher rates of ΔHb ≥30 g/l (P=0.002). Composite adverse maternal and neonatal outcomes were unaffected. CONCLUSION: On the grounds of increased maternal blood loss, and in contrast to the current International Federation of Gynecology and Obstetrics (FIGO) guideline, delayed active pushing is not recommended in nulliparous women with epidural analgesia.


Assuntos
Analgesia Epidural/efeitos adversos , Analgesia Obstétrica/efeitos adversos , Parto Obstétrico/métodos , Hemorragia Pós-Parto/etiologia , Adulto , Analgesia Obstétrica/métodos , Parto Obstétrico/efeitos adversos , Feminino , Humanos , Período Pós-Parto , Gravidez , Estudos Prospectivos , Fatores de Tempo , Adulto Jovem
5.
BMC Womens Health ; 20(1): 99, 2020 05 11.
Artigo em Inglês | MEDLINE | ID: mdl-32393225

RESUMO

BACKGROUND: Previous studies have demonstrated that appropriate treatment for postoperative pain can lead to improvement in depressive symptoms, however the association between adequate intrapartum pain control and the development of postpartum depression is not clear. The purpose of the study was to examine the effects of labor epidural analgesia and postpartum depression. METHODS: We performed a quantitative systematic review in compliance with the PRISMA statement. We conducted a search of PubMed, Embase, the Cochrane Database of Systematic Reviews and Google Scholar databases. The primary outcome was a positive screen of postpartum depression among women who received labor epidural analgesia up to 3 months into the postpartum period. Meta-analysis was performed using the random effect model. RESULTS: Of the 148 studies available, 9 studies with 4442 patients were included in the analysis. The use of labor analgesia on positive depression screen compared to control revealed no significant effect, OR (95% CI) of 1.02 (0.62 to 1.66, P = 0.94). CONCLUSION: Based on current literature, the use of epidural analgesia for pain relief during labor doesn't appear to affect the likelihood of postpartum depression. Future studies are warranted to further investigate these findings and identity other possible preventative interventions that reduce postpartum depression.


Assuntos
Analgesia Epidural/efeitos adversos , Analgésicos/uso terapêutico , Depressão Pós-Parto/diagnóstico , Depressão Pós-Parto/psicologia , Dor do Parto/terapia , Analgesia Epidural/métodos , Analgesia Epidural/psicologia , Depressão Pós-Parto/epidemiologia , Feminino , Humanos , Dor do Parto/psicologia , Manejo da Dor , Gravidez
6.
Curr Opin Anaesthesiol ; 33(3): 284-290, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32371639

RESUMO

PURPOSE OF REVIEW: Even if its use is scarce in most countries, many articles concerning combined spinal epidural (CSE) were published. In this review, we present the latest advances concerning CSE in obstetrics. RECENT FINDINGS: During labour, CSE improves epidural analgesia quality. Epidural with intradural opioids can produce maternal hypotension and foetal heart rate abnormalities (FHR-Ab), without increasing the caesarean section rate. For caesarean section, CSE decreases the neuraxial block failure rate, with no significant increase of complications. Epidural volume extension (EVE) after CSE for caesarean section could be an interesting option even though more evidence is needed. SUMMARY: For labour analgesia, CSE has the fastest onset time of analgesia. Its side effects have no consequences on maternal, labour or foetal outcomes. It provides better analgesia than epidural analgesia and can be used for external cephalic version and high-risk patients. For caesarean section, CSE has become the reference neuraxial technique for low-dose spinal anaesthesia, with higher success rate compared with regular spinal anaesthesia. Recent systematic revisions did not confirm this superiority. CSE offers the advantage of EVE, intraoperative top-ups, postoperative administration of neuraxial opioids and local anaesthetics. The risk of complications is balanced by the benefits of the technique.


Assuntos
Analgesia Epidural , Analgesia Obstétrica , Raquianestesia , Anestésicos Combinados/administração & dosagem , Analgesia Epidural/efeitos adversos , Analgesia Obstétrica/efeitos adversos , Anestesia Obstétrica , Raquianestesia/efeitos adversos , Cesárea , Espaço Epidural , Feminino , Humanos , Gravidez
7.
Rev. esp. anestesiol. reanim ; 67(4): 215-218, abr. 2020. ilus
Artigo em Espanhol | IBECS | ID: ibc-198032

RESUMO

Los déficits motores de miembros inferiores durante el embarazo y el puerperio son relativamente frecuentes. Se atribuyen habitualmente a complicaciones asociadas a las técnicas neuroaxiales que son realizadas por el anestesiólogo. Pero existen otras posibles causas, como la osteoporosis transitoria de caderas. La osteoporosis transitoria del embarazo es una patología infrecuente y autolimitada de origen desconocido. La complicación más severa que puede presentar son las fracturas patológicas, fundamentalmente en las articulaciones de carga. Esta patología suele presentarse en el tercer trimestre del embarazo y cursa con dolor e impotencia funcional del miembro inferior afecto. Presentamos el caso de una mujer de 35 años, gestante de 40+3 semanas que inicia trabajo de parto. Se coloca catéter epidural normofuncionante y finalmente se decide cesárea por parto estacionado; 48h después comienza con impotencia funcional en miembro inferior izquierdo y dolor. Se realiza RM donde se descarta hematoma epidural y se objetiva osteopenia de caderas, siendo diagnosticada de osteoporosis transitoria el embarazo


Motor deficits of lower limbs during pregnancy and the puerperium are relatively frequent. They are usually attributed to complications which are associated with neuroaxial techniques performed by the anesthesiologist. But there are other possible causes, such as transient osteoporosis of the hips. Transient osteoporosis of pregnancy is a rare and self-limited pathology of unknown etiology. The most severe complication that can occur are pathological fractures, mainly in the load joints. This pathology usually occurs in the third trimester of pregnancy and is showed up with pain and functional impotence of the lower limb affected. We present the case of a 35-year-old woman, 40+3 weeks of pregnancy who starts labour. Normally functioning epidural catheter is placed and finally cesarean section is decided because failure to progress; 48h later the patient begins with functional impotence and pain in the lower left limb. MRI is performed, epidural hematoma is ruled out and osteopenia of the hips is proved. The patient is diagnosed with transient osteoporosis of pregnancy


Assuntos
Humanos , Feminino , Gravidez , Adulto , Osteoporose/diagnóstico por imagem , Doenças Ósseas Metabólicas/diagnóstico por imagem , Quadril/fisiopatologia , Cesárea , Complicações na Gravidez/diagnóstico por imagem , Terceiro Trimestre da Gravidez , Imagem por Ressonância Magnética , Período Pós-Parto , Analgesia Epidural/efeitos adversos
8.
PLoS One ; 15(3): e0229898, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32142529

RESUMO

OBJECTIVES: To test the feasibility of a randomized controlled study design comparing epidural analgesia (EDA) with continuous wound infiltration (CWI) in respect to postoperative complications and mobility to design a future multicentre randomized controlled trial. DESIGN, SETTING, PARTICIPANTS: CWI has been developed to address drawbacks of EDA. Previous studies have established the equivalent analgesic potential of CWI compared to EDA. This is a single centre, non-blinded pilot randomized controlled trial at a tertiary surgical centre. Patients undergoing elective non-colorectal surgery via a midline laparotomy were randomized to EDA or CWI. Endpoints included recruitment, feasibility of assessing postoperative mobility with a pedometer and morbidity. No primary endpoint was defined and all analyses were explorative. INTERVENTIONS: CWI with local anaesthetics (experimental group) vs. thoracic EDA (control). RESULTS: Of 846 patients screened within 14 months, 71 were randomized and 62 (31 per group) included in the intention-to-treat analysis. Mobility was assessed in 44 of 62 patients and revealed no differences within the first 3 postoperative days. Overall morbidity did not differ between the two groups (measured via the comprehensive complication index). Median pain scores at rest were comparable between the two groups, while EDA was superior in pain treatment during movement on the first, but not on the second and third postoperative day. Duration of preoperative induction of anaesthesia was shorter with CWI than with EDA. Of 17 serious adverse events, 3 were potentially related to EDA, while none was related to CWI. CONCLUSION: This trial confirmed the feasibility of a randomized trial design to compare CWI and EDA regarding morbidity. Improvements in the education and training of team members are necessary to improve recruitment. TRIAL REGISTRATION: DRKS00008023.


Assuntos
Traumatismos Abdominais/cirurgia , Analgesia Epidural/métodos , Anestesia Local/métodos , Anestésicos Locais/administração & dosagem , Traumatismos Abdominais/tratamento farmacológico , Traumatismos Abdominais/fisiopatologia , Analgesia Epidural/efeitos adversos , Anestesia Local/efeitos adversos , Procedimentos Cirúrgicos Eletivos/normas , Feminino , Humanos , Laparotomia/normas , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Medição da Dor/métodos , Dor Pós-Operatória/fisiopatologia , Dor Pós-Operatória/prevenção & controle , Projetos Piloto , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/prevenção & controle , Período Pós-Operatório
9.
Anaesthesia ; 75(7): 913-919, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32115697

RESUMO

Serious neurological lesions such as vertebral canal haematoma are rare after obstetric regional analgesia/anaesthesia, but early detection may be crucial to avoid permanent damage. This may be hampered by the variable and sometimes prolonged recovery following 'normal' neuraxial block, such that an underlying lesion may easily be missed. These guidelines make recommendations for the monitoring of recovery from obstetric neuraxial block, and escalation should recovery be delayed or new symptoms develop, with the aim of preventing serious neurological morbidity.


Assuntos
Analgesia Obstétrica/métodos , Anestesia Obstétrica/métodos , Monitorização Neurofisiológica/métodos , Analgesia Epidural/efeitos adversos , Analgesia Epidural/métodos , Analgesia Epidural/normas , Analgesia Obstétrica/efeitos adversos , Analgesia Obstétrica/normas , Período de Recuperação da Anestesia , Anestesia por Condução/efeitos adversos , Anestesia por Condução/métodos , Anestesia por Condução/normas , Anestesia Obstétrica/efeitos adversos , Anestesia Obstétrica/normas , Feminino , Hematoma Epidural Espinal/diagnóstico , Hematoma Epidural Espinal/etiologia , Humanos , Doenças do Sistema Nervoso/diagnóstico , Doenças do Sistema Nervoso/etiologia , Monitorização Neurofisiológica/normas , Segurança do Paciente , Cuidado Pós-Natal/métodos , Cuidado Pós-Natal/normas , Gravidez , Transtornos Puerperais/diagnóstico , Transtornos Puerperais/etiologia , Fatores de Risco
10.
Arch Gynecol Obstet ; 301(5): 1153-1158, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32219521

RESUMO

PURPOSE: The purpose of this study was to study the impact of epidural analgesia using low-concentration local anesthetic during the entire labor on maternal and neonatal outcomes. METHODS: The authors enrolled 2310 parturient mothers who underwent vaginal delivery at their hospital since January 1, 2019. The parturients were allocated either into the analgesia or into the non-analgesia groups based on whether they received analgesia during the delivery process. To investigate the effects of epidural analgesia using low-concentration local anesthetic on maternal and neonatal outcomes, the authors assessed between-group differences in the labor duration, newborn Apgar score, and maternal and neonatal outcomes. RESULTS: Compared to the non-analgesia group, the first and second labor stage durations in the analgesia group were significantly longer. Similarly, the analgesia group had a higher frequency of oxytocin injections, Category II and III fetal heart rate tracing during labor, and intrapartum fever development. Further, the need for episiotomy and assisted vaginal delivery was higher in the analgesia group than that in the non-analgesia group. Regarding neonatal outcomes, the neonatal hospitalization rate and incidence rate of umbilical cord blood pH < 7.2 were higher in the analgesia group than those in the non-analgesia group. However, there were no significant between-group differences in the incidence rates of stained amniotic fluid, mild neonatal asphyxia, and severe perinatal asphyxia. CONCLUSION: Patient-controlled epidural analgesia using low-concentration local anesthetic during the entire labor did not increase the incidence rate of severe adverse outcomes in neonates born through vaginal delivery; however, it increased the delivery duration, and thus, the chance of possible perinatal interventions.


Assuntos
Analgesia Epidural/efeitos adversos , Analgesia Obstétrica/efeitos adversos , Anestésicos Locais/uso terapêutico , Adulto , Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Anestésicos Locais/farmacologia , Feminino , Humanos , Recém-Nascido , Masculino , Gravidez , Estudos Prospectivos , Resultado do Tratamento
12.
Curr Opin Anaesthesiol ; 33(3): 305-310, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32049882

RESUMO

PURPOSE OF REVIEW: Preeclampsia remains an important cause of maternal and neonatal morbidity and mortality. Recent interest in angiogenic biomarkers as a prognostic indicator is reviewed, together with analgesic, anaesthetic and critical-care management of the preeclamptic patient. RECENT FINDINGS: There has been recent interest in the angiogenic biomarkers placental growth factor and soluble fms-like tyrosine kinase-1 in establishing the diagnosis of preeclampsia and guiding its management. Neuraxial blocks are recommended for both labour and operative delivery if not contraindicated by thrombocytopenia or coagulopathy, although a safe lower limit for platelet numbers has not been established. For spinal hypotension phenylephrine is noninferior to ephedrine in preeclamptic parturients and may offer some benefits. When general anaesthesia is required, efforts must be made to blunt the hypertensive response to laryngoscopy and intubation. Transthoracic echocardiography has emerged as useful technique to monitor maternal haemodynamics in preeclampsia. SUMMARY: Improvements in the diagnosis of preeclampsia may lead to better outcomes for mothers and babies. Peripartum care requires a multidisciplinary team approach with many preeclamptic women receiving neuraxial analgesia or anaesthesia. Women with severe preeclampsia may require critical-care support and this should meet the same standards afforded to other acutely unwell patients.


Assuntos
Anestesia Obstétrica , Anestesiologistas , Hemodinâmica/fisiologia , Bloqueio Nervoso , Pré-Eclâmpsia/fisiopatologia , Adulto , Analgesia Epidural/efeitos adversos , Anestesia Geral , Anestesia Obstétrica/efeitos adversos , Biomarcadores , Ecocardiografia , Feminino , Humanos , Período Periparto , Fator de Crescimento Placentário , Gravidez , Prognóstico
13.
Medicine (Baltimore) ; 99(5): e18862, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32000389

RESUMO

INTRODUCTION: Horner's syndrome is an unusual side effect of epidural analgesia. We report an unusual symptom after epineural axis analgesia for labor, which happened three times in the same patient. Horner's syndrome occurrence following epidural catheterization should lead the anesthetic team to search for a subdural position of the catheter because of its potentially threatening complications. PATIENT'S CONCERN: Our patient, a 38 years old pregnant woman, was managed by the anesthetic team for the analgesia of her second labor. Anesthetic consultation pointed out that she had a history of Horner's syndrome after epidural analgesia attempt during her first pregnancy.During our anesthetic management of her second labor, she presented, on the left side of the body, with the same symptom as she had during her first labor a few years ago, associated with high unilateral sensory block after epidural catheterization. After the total regression of neurological signs, a second catheterization attempt was followed by a contralateral isolated Horner's syndrome with no sensory block. DIAGNOSIS: A few minutes after the induction of analgesia, our patient presented left ptosis, meiosis, and enophthalmos associated with a high homolateral sensory block. The subdural catheter position was suspected, and the catheter was removed. INTERVENTION: Because of this repeated unusual complication and because we would not have used the catheter for an emergency C section, we chose to remove it definitively. OUTCOME: Our patient had a total regression of the symptoms 1 h after the catheter withdrawal. Delivery was rapid, with no complications, and she was discharged from the hospital 3 days after. CONCLUSION: Our observations suggest the possibility of a potential anatomical particularity of the dural canal in this patient and question the safety of performing an epidural catheterization for further procedures.


Assuntos
Analgesia Epidural/efeitos adversos , Síndrome de Horner/etiologia , Adulto , Feminino , Humanos , Gravidez
14.
Br J Hosp Med (Lond) ; 81(1): 1-7, 2020 Jan 02.
Artigo em Inglês | MEDLINE | ID: mdl-32003627

RESUMO

Epidural analgesia is a key component in the management of inpatient pain relief, particularly in surgical and trauma patients, and those with comorbidities. When used appropriately epidurals can decrease a patient's opiate consumption, as well as reducing the risk of adverse cardiorespiratory outcomes. To non-anaesthetists, or those not versed in their usage, epidurals can appear complex and intimidating, and the potential complications, although rare, can be catastrophic if not picked up on in a timely fashion. This article demystifies the epidural for hospital clinicians, looking at the anatomy and pharmacology, helping to identify patients who may benefit from epidural analgesia, highlighting some common pitfalls and questions posed by nursing staff, and providing a framework via which junior clinicians can detect, manage and appropriately escalate epidural-related problems and complications. Epidural analgesia is an invasive and high-risk intervention; as such it should always be managed by a multidisciplinary team, including anaesthesia and acute pain services.


Assuntos
Analgesia Epidural , Analgésicos Opioides/administração & dosagem , Dor Pós-Operatória/tratamento farmacológico , Analgesia Epidural/efeitos adversos , Analgesia Epidural/enfermagem , Analgésicos Opioides/farmacologia , Tomada de Decisão Clínica , Medicina Baseada em Evidências , Humanos , Manejo da Dor
15.
Curr Pain Headache Rep ; 24(1): 1, 2020 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-31916041

RESUMO

PURPOSE OF REVIEW: Post dural puncture headache (PDPH) is a relatively common complication which may occur in the setting of inadvertent dural puncture (DP) during labor epidural analgesia and during intentional DP during spinal anesthetic placement or diagnostic lumbar puncture. Few publications have established the long-term safety of an epidural blood patch (EBP) for the treatment of a PDPH. RECENT FINDINGS: The aim of this pilot study was to examine the association of chronic low back pain (LBP) in patients who experienced a PDPH following labor analgesia and were treated with an EBP. A total of 146 patients were contacted and completed a survey questionnaire via telephone. The EBP group was found to be more likely to have chronic LBP (percentage difference 20% [95% CI 6-33%], RR 2.6 [95% CI 1.3-5.2]) and also LBP < 6 (percentage difference 24% [95% CI 9- 37%], RR 2.3 [95% CI 1.3-4.1]). There were no significant differences in the severity and descriptive qualities of pain between the EBP and non-EBP groups. Our findings suggest that PDPH treated with an EBP is associated with an increased prevalence of subsequent low back pain in parturients. The findings of this pilot study should spur further prospective research into identifying potential associations between DP, EBP, and chronic low back pain.


Assuntos
Analgesia Epidural/efeitos adversos , Analgesia Obstétrica/efeitos adversos , Placa de Sangue Epidural/efeitos adversos , Dor Crônica/epidemiologia , Dor Lombar/epidemiologia , Cefaleia Pós-Punção Dural/terapia , Adulto , Estudos de Casos e Controles , Feminino , Humanos , Projetos Piloto , Cefaleia Pós-Punção Dural/complicações
16.
J Obstet Gynaecol Res ; 46(1): 104-109, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31621113

RESUMO

AIM: This study aimed to investigate the rate of labor-onset hypertension (LOH) under neuraxial labor analgesia and the effect of neuraxial labor analgesia on LOH. METHODS: A retrospective study was conducted in a tertiary university hospital from 2015 to 2016. Patients who were admitted to the hospital for vaginal delivery under combined spinal and epidural anesthesia were selected. LOH was defined as the elevation of systolic blood pressure (BP) to ≥140 mmHg or diastolic BP to ≥90 mmHg for the first time after the onset of labor. Cases of LOH that persisted after neuraxial labor analgesia (prolonged LOH) were further analyzed to determine the hypertension severity and therapeutic intervention rate. RESULTS: Among 775 patients, 213 (28.4%) developed LOH. Prolonged LOH was observed in 30 patients (3.9%). LOH severity and the likelihood of prolonged LOH were positively correlated. Therapeutic intervention was administered only to the patients with prolonged LOH, that is, to 100% of those with emergent hypertension, to 21.1% of those with severe hypertension during labor, and to 36.8% of those with severe hypertension, to 55.6% of those with mild hypertension in the post-partum period. CONCLUSION: The rate of LOH was reduced significantly after neuraxial labor analgesia. Patients with prolonged LOH should be carefully followed up during labor and in the post-partum period because such patients often require antihypertensive therapy.


Assuntos
Analgesia Epidural/efeitos adversos , Analgesia Obstétrica/efeitos adversos , Pressão Sanguínea/efeitos dos fármacos , Hipertensão/induzido quimicamente , Complicações do Trabalho de Parto/induzido quimicamente , Adulto , Feminino , Humanos , Hipertensão/epidemiologia , Hipertensão/fisiopatologia , Trabalho de Parto/fisiologia , Complicações do Trabalho de Parto/epidemiologia , Complicações do Trabalho de Parto/fisiopatologia , Gravidez , Estudos Retrospectivos , Adulto Jovem
17.
Pain Pract ; 20(3): 321-324, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31529606

RESUMO

INTRODUCTION: Epidural infusion of local anesthetics with opioids is widely used for pain control during the perioperative-and peripartum-periods. Selection of the opioid, appropriate dosing, and follow-up by the acute pain service are critical in providing safe postoperative epidural analgesia. CASE REPORT SUMMARY: A 71-year-old man was scheduled for a parastomal hernia repair with midline laparotomy. The parastomal hernia was a complication from a previously performed colectomy for ulcerative colitis. Preoperatively, the patient received a lower thoracic epidural catheter. The epidural infusate (0.2% ropivacaine with 0.5 µg/mL sufentanil) was prepared and double-checked by holding area nurses. The fact that the right prescription medication label partially covered a morphine label went unnoticed. The intraoperative phase was characterized by stable parameters. Postoperatively, it was not possible to demonstrate an epidural nerve block. No pain was reported, and the patient could be transferred to the ward. The patient developed coma and delayed respiratory depression after discharge to the surgical ward, requiring intensive care unit admission and naloxone administration. Analysis of the syringe content revealed the presence of morphine (1 mg/mL). DISCUSSION: Color-coded prefilled syringes combined with the use of an epidural specific syringe connector to prevent cross-connections should become standard practice. In addition, delayed respiratory depression should be considered after epidural administration of morphine.


Assuntos
Analgesia Epidural/efeitos adversos , Coma/induzido quimicamente , Erros de Medicação/efeitos adversos , Morfina/efeitos adversos , Insuficiência Respiratória/induzido quimicamente , Idoso , Analgesia Epidural/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem
18.
Ann Vasc Surg ; 66: 44-53, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31672606

RESUMO

BACKGROUND: Epidural analgesia (EA) is frequently used as an adjuvant to general anesthesia (GA) for improved postoperative analgesia and reduced rates of cardiac, pulmonary, and renal complications. However, only a few studies have examined EA-GA specifically during open abdominal aortic aneurysm (AAA) repair. The effects of EA-GA specifically during open AAA repair regarding postoperative outcomes are unknown. This study was performed to evaluate postoperative outcomes in patients undergoing open AAA repair with EA-GA versus GA alone. METHODS: We performed a retrospective analysis for patients undergoing surgery between January 1, 2014 and December 31, 2016 using the National Surgical Quality Improvement Program (NSQIP) database. Propensity score matching was used to establish cohorts for analysis. Multivariable logistic regression was performed to determine significant perioperative outcomes for each anesthesia type. A total of 2,171 patients underwent open AAA repair in our date range; we excluded emergent and ruptured AAA. A total of 2,145 patients were included in our analysis, of whom 653 patients received EA-GA and 1,492 patients received GA only. RESULTS: Major postoperative outcomes included mortality, pulmonary cardiac and renal complications, infections, thrombosis, and blood transfusion requirement (including Cell-Saver usage). Additional overall outcomes included hospital length of stay, return to the operating room, and readmission. Patients in EA + GA and GA alone groups were comparable regarding demographics, functional status, and comorbidities. Decreased odds of readmission was observed in EA + GA compared with GA (0.49, 95% CI [0.28-0.86]; P = 0.014); and increased odds of receiving a blood transfusion was observed in those who underwent EA + GA (1.63, 95% CI [1.23-2.14]; P = 0.001). No difference was observed between patients who had an AAA repair with EA + GA versus GA alone with regard to mortality, return to operating room, major pulmonary, cardiac, renal, or infectious complications. CONCLUSIONS: EA + GA was not associated with decreased mortality or decreased rates of major postoperative pulmonary, cardiac, or renal complications. EA + GA was associated with increased transfusion requirements and decreased rates of hospital readmission.


Assuntos
Analgesia Epidural , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Dor Pós-Operatória/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Analgesia Epidural/efeitos adversos , Analgesia Epidural/mortalidade , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Transfusão de Sangue , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Bases de Dados Factuais , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/mortalidade , Readmissão do Paciente , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
19.
BMC Pregnancy Childbirth ; 19(1): 498, 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31842795

RESUMO

BACKGROUND: The trial of labor after cesarean section (TOLAC) is a relatively new technique in mainland of China, and epidural analgesia is one of the risk factors for uterine rupture. This study aimed to evaluate the effect of epidural analgesia on primary labor outcome [success rate of vaginal birth after cesarean (VBAC)], parturient complications and neonatal outcomes after TOLAC in Chinese multiparas based on a strictly uniform TOLAC indication, management and epidural protocol. METHODS: A total of 423 multiparas undergoing TOLAC were enrolled in this study from January 2017 to February 2018. Multiparas were divided into two groups according to whether they received epidural analgesia (study group, N = 263) or not (control group, N = 160) during labor. Maternal delivery outcomes and neonatal characteristics were recorded and evaluated using univariate analysis, multivariable logistic regression and propensity score matching (PSM). RESULTS: The success rate of VBAC was remarkably higher (85.55% vs. 69.38%, p < 0.01) in study group. Epidural analgesia significantly shortened initiating lactation period and declined Visual Analogue Score (VAS). It also showed more superiority in neonatal umbilical arterial blood pH value. After matching by PSM, multivariable logistic regression revealed that the correction of confounding factors including epidural analgesia, cervical Bishop score at admission and spontaneous onset of labor were still shown as promotion probability in study group (OR = 4.480, 1.360, and 10.188, respectively; 95%CI = 2.025-10.660, 1.113-1.673, and 2.875-48.418, respectively; p < 0.001, p = 0.003, and p < 0.001, respectively). CONCLUSIONS: Epidural analgesia could reduce labor pain, and no increased risk of postpartum bleeding or uterine rupture, as well as adverse effects in newborns were observed. The labor duration of multiparas was increased, but within acceptable range. In summary, epidural analgesia may be safe for both mother and neonate in the three studied hospitals. TRIAL REGISTRATION: Chineses Clinical Trial Register, ChiCTR-ONC-17010654. Registered February 16th, 2017.


Assuntos
Analgesia Epidural/efeitos adversos , Analgesia Obstétrica/efeitos adversos , Dor do Parto/tratamento farmacológico , Complicações do Trabalho de Parto/epidemiologia , Prova de Trabalho de Parto , Adulto , China/epidemiologia , Feminino , Humanos , Recém-Nascido , Modelos Logísticos , Complicações do Trabalho de Parto/induzido quimicamente , Hemorragia Pós-Parto/induzido quimicamente , Hemorragia Pós-Parto/epidemiologia , Gravidez , Resultado da Gravidez , Estudos Prospectivos , Fatores de Risco , Ruptura Uterina/induzido quimicamente , Ruptura Uterina/epidemiologia
20.
Drug Des Devel Ther ; 13: 3785-3798, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31802851

RESUMO

Background: Post-anesthetic shivering incurs discomfort to patients or even exacerbates their condition. However, no ideal drug has been well established for preventing post-anesthetic shivering. Currently, subarachnoid and epidural dexmedetomidine have demonstrated to have an anti-shivering effect. Methods: An electronic search was conducted to identify randomized placebo-controlled trials reporting shivering and then compared subarachnoid and epidural dexmedetomidine with placebo in adults undergoing selective surgery. Data assessment and pooling were analyzed by Review Manager 5.3, STATA 15.0 and GRADE-pro 3.6 software. Results: Twenty-two studies (1389 patients) were subjected to this meta-analysis. The incidence of post-anesthetic shivering decreased from 20.10% in the placebo group to 10.30% in the dexmedetomidine group (RR, 0.48; 95% CI, 0.39-0.59; Z=6.86, P<0.00001, I 2=32%). Non-Indian, epidural-space route and cesarean subgroups indicated a better anti-shivering effect. In the subarachnoid-space route subgroup, a dosage of >5 µg showed significantly superior anti-shivering effects than that of ≤5 µg. Subarachnoid and epidural dexmedetomidine increased the incidence of bradycardia, had no impact on nausea and vomiting, shortened the onset of block and lengthened the duration of block and analgesia. However, its effect on hypotension and sedation remained uncertain. The overall risk of bias was relatively low. The level of evidence was high, and the recommendation of voting results was strong. Conclusion: Dexmedetomidine as a subarachnoid and epidural adjunct drug could decrease the incidence of post-anesthetic shivering in a dose-dependent manner. However, caution should be taken in patients with original bradycardia.


Assuntos
Analgesia Epidural/efeitos adversos , Dexmedetomidina/farmacologia , Dexmedetomidina/uso terapêutico , Tremor por Sensação de Frio/efeitos dos fármacos , Relação Dose-Resposta a Droga , Humanos , Estrutura Molecular , Relação Estrutura-Atividade
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