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4.
Anaesth Intensive Care ; 48(5): 381-388, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33021807

RESUMO

The reported incidence of post--dural puncture headache (PDPH) after neuraxial anaesthesia varies widely, depending on patient and procedural risk factors. Most previous studies have had small sample sizes and focused on obstetric patients. This study aimed to investigate the incidence of PDPH and factors associated with PDPH in non-obstetric and obstetric patients after neuraxial anaesthesia. We identified patients who underwent surgery with neuraxial anaesthesia between July 2010 and December 2017 from a Japanese nationwide inpatient administrative claims and discharge database. Factors associated with PDPH (body mass index (BMI), depression, spinal abnormalities, academic hospital and location of epidural anaesthesia) were examined using multivariable logistic analyses. The incidence of PDPH in non-obstetric patients after spinal anaesthesia, epidural anaesthesia and combined spinal epidural anaesthesia was 0.16%, 0.13% and 0.23% and in obstetric patients was 1.16%, 0.99% and 1.05%, respectively. Higher BMI was associated with decreased incidence of PDPH in non-obstetric patients receiving spinal anaesthesia and obstetric patients receiving epidural anaesthesia. In female patients receiving spinal anaesthesia, a history of depression was associated with increased incidence of PDPH. Being in an academic hospital was associated with decreased incidence of PDPH in male patients receiving spinal anaesthesia and female patients receiving spinal or epidural anaesthesia, but increased incidence of PDPH in male patients receiving epidural anaesthesia. Lumbar epidural anaesthesia was associated with increased incidence of PDPH in male patients, but decreased incidence of PDPH in obstetric patients compared with thoracic epidural anaesthesia. The present study identified several potential new risk factors for PDPH, and revealed that the incidence of PDPH in non-obstetric patients after neuraxial anaesthesia was lower than in obstetric patients.


Assuntos
Anestesia Obstétrica , Raquianestesia , Cefaleia Pós-Punção Dural , Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Placa de Sangue Epidural , Feminino , Cefaleia , Humanos , Incidência , Pacientes Internados , Japão/epidemiologia , Masculino , Cefaleia Pós-Punção Dural/epidemiologia , Cefaleia Pós-Punção Dural/etiologia , Gravidez , Punções , Fatores de Risco
5.
Curr Opin Anaesthesiol ; 33(6): 793-799, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33002958

RESUMO

PURPOSE OF REVIEW: Recognition of the increasing maternal mortality rate in the United States has been accompanied by intense efforts to improve maternal safety. This article reviews recent advances in maternal safety, highlighting those of particular relevance to anesthesiologists. RECENT FINDINGS: Cardiovascular and other chronic medical conditions contribute to an increasing number of maternal deaths. Anesthetic complications associated with general anesthesia are decreasing, but complications associated with neuraxial techniques persist. Obstetric early warning systems are evolving and hold promise in identifying women at risk for adverse intrapartum events. Postpartum hemorrhage rates are rising, and rigorous evaluation of existing protocols may reveal unrecognized deficiencies. Development of regionalized centers for high-risk maternity care is a promising strategy to match women at risk for adverse events with appropriate resources. Opioids are a growing threat to maternal safety. There is growing evidence for racial inequities and health disparities in maternal morbidity and mortality. SUMMARY: Anesthesiologists play an essential role in ensuring maternal safety. While continued intrapartum vigilance is appropriate, addressing the full spectrum of contributors to maternal mortality, including those with larger roles beyond the immediate peripartum time period, will be essential to ongoing efforts to improve maternal safety.


Assuntos
Analgesia Obstétrica/tendências , Anestesia Obstétrica/tendências , Anestesiologistas/psicologia , Parto Obstétrico/tendências , Mortalidade Materna/tendências , Hemorragia Pós-Parto/prevenção & controle , Analgesia Obstétrica/efeitos adversos , Analgesia Obstétrica/métodos , Anestesia Obstétrica/efeitos adversos , Anestesia Obstétrica/métodos , Parto Obstétrico/efeitos adversos , Parto Obstétrico/métodos , Feminino , Humanos , Serviços de Saúde Materna/normas , Erros Médicos/prevenção & controle , Gravidez , Complicações na Gravidez , Estados Unidos
6.
Br J Anaesth ; 125(4): 580-587, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32736825

RESUMO

BACKGROUND: Data on UK obstetric anaesthetic practice between 2009 and 2014 were collected by the Obstetric Anaesthetists' Association's National Obstetric Anaesthetic Database. This database provides information on workload, variation in practice, and complication rates. METHODS: During 2009-14, data were submitted by 190 UK hospitals. The number of hospitals that submitted data each year ranged between 114 and 145. During this 6 yr period, between 27 and 35 data items were requested, although not all hospitals submitted information on all data items. The dataset was assessed for quality and only those data items with acceptable quality were analysed. RESULTS: The dataset contains information on 3 030 493 deliveries, 770 545 Caesarean sections, 623 050 women with labour neuraxial analgesia, and 61 121 general anaesthetics for Caesarean section. There was increased use of patient-controlled regimens for labour neuraxial analgesia over the 6 yr period. The mean rate of general anaesthesia used for Caesarean section was 8.75% (95% confidence interval, 8.26-9.24%). The rate of failed intubation for general anaesthesia for Caesarean section was one in 379. Inadvertent dural puncture rates varied between hospitals with a mean of 1.2% (95% confidence interval, 1.02-1.37%). The rate of a high neuraxial block causing unconsciousness was one in 6667 for all blocks. CONCLUSIONS: This unique large dataset provides a valuable insight of obstetric anaesthetic activity in the UK. Although missing data may place limitations on interpretation, it provides comparative estimates for the rates of rare complications and highlights variations in practice in time and place.


Assuntos
Anestesia Obstétrica , Analgesia Obstétrica , Anestesia Geral , Anestesia Obstétrica/efeitos adversos , Anestesia Obstétrica/métodos , Cesárea , Análise de Dados , Bases de Dados Factuais , Conjuntos de Dados como Assunto , Feminino , Humanos , Unidades de Terapia Intensiva , Bloqueio Nervoso/efeitos adversos , Bloqueio Nervoso/métodos , Gravidez , Reino Unido
7.
Am J Obstet Gynecol ; 223(5): 747.e1-747.e13, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32791121

RESUMO

BACKGROUND: Maternal hypotension after spinal anesthesia, and time from anesthesia to delivery, are potentially modifiable risk factors for neonatal acidosis. OBJECTIVE: This study aimed to examine the relationship between the time from spinal anesthesia to delivery and spinal hypotension in planned cesarean deliveries and their effect on neonatal outcome, primarily neonatal acidosis. STUDY DESIGN: We performed a retrospective analysis of women with singleton pregnancy undergoing spinal anesthesia for planned cesarean delivery between 37 0/7 and 41 6/7 weeks' gestation using electronic medical records. The occurrence of spinal hypotension and anesthesia-to-incision and incision-to-delivery intervals (minutes) were the primarily studied variables. In addition, spinal hypotension index was developed to account for the duration and magnitude of maternal hypotension. The 90th percentile for the spinal hypotension index defined the sustained spinal hypotension group. The primary outcome was neonatal acidosis (pH of ≤7.1 or base deficit of ≥12.0). The odds ratios were calculated using univariate and multivariate logistic regression models. The multivariate analysis included sporadic spinal hypotension or sustained spinal hypotension, use of vasopressor treatment, and anesthesia-to-incision and incision-to-delivery intervals. RESULTS: We included 3150 women in the study. Notably, 43.4% experienced at least 1 event of spinal hypotension (sporadic) and 14.8% experienced sustained spinal hypotension. Neonatal acidosis occurred in 3.4% cases of sporadic spinal hypotension (odds ratio, 1.83; 95% confidence interval, 2.27-2.87) and in 5.8% cases of sustained hypotension (odds ratio, 3.00; 95% confidence interval, 1.87-4.80). Both anesthesia-to-incision and incision-to-delivery intervals were significantly associated with neonatal acidosis as follows: at 90th percentile cutoff, the odds ratios for neonatal acidosis were 3.82 (95% confidence interval, 2.03-7.19) and 2.94 (95% confidence interval, 1.70-5.10), respectively. The use of ephedrine (odds ratio, 2.42; 95% confidence interval, 1.35-4.32) but not phenylephrine (odds ratio, 0.76; 95% confidence interval, 0.34-1.72) treatment was also associated with more cases of neonatal acidosis. The woman's age, gestational age, neonatal birthweight, fetal presentation, and the number of previous cesarean deliveries were not associated with neonatal acidosis. In multivariate analysis, anesthesia-to-incision and incision-to-delivery intervals, use of vasopressor treatment, and sustained spinal hypotension were independently associated with neonatal acidosis. After adjustment, the risk for neonatal acidosis did not increase in women who experienced sporadic spinal hypotension only. Neither neonatal acidosis nor the primary research variables were associated with neonatal complications such as transient tachypnea of the newborn, respiratory distress, or admission to the neonatal unit. CONCLUSION: Neonatal acidosis in planned cesarean delivery was common. However, serious perinatal consequences were rare. The adverse effects of sustained spinal hypotension and prolonged anesthesia-to-incision and incision-to-delivery intervals on neonatal acid-base balance were additive. This supports the adoption of prevention strategies for spinal hypotension, which is widely evidenced based on the obstetrical anesthesia literature, but still not universally used. Whether the reduction in intraoperative time intervals would benefit the neonate should be determined by future prospective studies.


Assuntos
Acidose/epidemiologia , Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Cesárea/métodos , Hipotensão/etiologia , Doenças do Recém-Nascido/epidemiologia , Vasoconstritores/uso terapêutico , Adulto , Índice de Apgar , Apresentação Pélvica , Recesariana/métodos , Efedrina/uso terapêutico , Feminino , Macrossomia Fetal , Humanos , Hipotensão/tratamento farmacológico , Recém-Nascido , Terapia Intensiva Neonatal/estatística & dados numéricos , Análise Multivariada , Fenilefrina/uso terapêutico , Gravidez , Síndrome do Desconforto Respiratório do Recém-Nascido/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Taquipneia Transitória do Recém-Nascido/epidemiologia
9.
Cochrane Database Syst Rev ; 7: CD002251, 2020 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-32619039

RESUMO

BACKGROUND: Maternal hypotension is the most frequent complication of spinal anaesthesia for caesarean section. It can be associated with nausea or vomiting and may pose serious risks to the mother (unconsciousness, pulmonary aspiration) and baby (hypoxia, acidosis, neurological injury). OBJECTIVES: To assess the effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (9 August 2016) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials, including full texts and abstracts, comparing interventions to prevent hypotension with placebo or alternative treatment in women having spinal anaesthesia for caesarean section. We excluded studies if hypotension was not an outcome measure. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study quality and extracted data from eligible studies. We report 'Summary of findings' tables using GRADE. MAIN RESULTS: We included 125 studies involving 9469 women. Interventions were to prevent maternal hypotension following spinal anaesthesia only, and we excluded any interventions considered active treatment. All the included studies reported the review's primary outcome. Across 49 comparisons, we identified three intervention groups: intravenous fluids, pharmacological interventions, and physical interventions. Authors reported no serious adverse effects with any of the interventions investigated. Most trials reported hypotension requiring intervention and Apgar score of less than 8 at five minutes as the only outcomes. None of the trials included in the comparisons we describe reported admission to neonatal intensive care unit. Crystalloid versus control (no fluids) Fewer women experienced hypotension in the crystalloid group compared with no fluids (average risk ratio (RR) 0.84, 95% confidence interval (CI) 0.72 to 0.98; 370 women; 5 studies; low-quality evidence). There was no clear difference between groups in numbers of women with nausea and vomiting (average RR 0.19, 95% CI 0.01 to 3.91; 1 study; 69 women; very low-quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (60 babies, low-quality evidence). Colloid versus crystalloid Fewer women experienced hypotension in the colloid group compared with the crystalloid group (average RR 0.69, 95% CI 0.58 to 0.81; 2009 women; 27 studies; very low-quality evidence). There were no clear differences between groups for maternal hypertension requiring intervention (average RR 0.64, 95% CI 0.09 to 4.46, 3 studies, 327 women; very low-quality evidence), maternal bradycardia requiring intervention (average RR 0.98, 95% CI 0.54 to 1.78, 5 studies, 413 women; very low-quality evidence), nausea and/or vomiting (average RR 0.89, 95% CI 0.66 to 1.19, 14 studies, 1058 women, I² = 29%; very low-quality evidence), neonatal acidosis (average RR 0.83, 95% CI 0.15 to 4.52, 6 studies, 678 babies; very low-quality evidence), or Apgar score of less than 8 at five minutes (average RR 0.24, 95% CI 0.03 to 2.05, 10 studies, 730 babies; very low-quality evidence). Ephedrine versus phenylephrine There were no clear differences between ephedrine and phenylephrine groups for preventing maternal hypotension (average RR 0.92, 95% CI 0.71 to 1.18; 401 women; 8 studies; very low-quality evidence) or hypertension (average RR 1.72, 95% CI 0.71 to 4.16, 2 studies, 118 women, low-quality evidence). Rates of bradycardia were lower in the ephedrine group (average RR 0.37, 95% CI 0.21 to 0.64, 5 studies, 304 women, low-quality evidence). There was no clear difference in the number of women with nausea and/or vomiting (average RR 0.76, 95% CI 0.39 to 1.49, 4 studies, 204 women, I² = 37%, very low-quality evidence), or babies with neonatal acidosis (average RR 0.89, 95% CI 0.07 to 12.00, 3 studies, 175 babies, low-quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (321 babies; low-quality evidence). Ondansetron versus control Ondansetron administration was more effective than control (placebo saline) for preventing hypotension requiring treatment (average RR 0.67, 95% CI 0.54 to 0.83; 740 women, 8 studies, low-quality evidence), bradycardia requiring treatment (average RR 0.49, 95% CI 0.28 to 0.87; 740 women, 8 studies, low-quality evidence), and nausea and/or vomiting (average RR 0.35, 95% CI 0.24 to 0.51; 653 women, 7 studies, low-quality evidence). There was no clear difference between the groups in rates of neonatal acidosis (average RR 0.48, 95% CI 0.05 to 5.09; 134 babies; 2 studies, low-quality evidence) or Apgar scores of less than 8 at five minutes (284 babies, low-quality evidence). Lower limb compression versus control Lower limb compression was more effective than control for preventing hypotension (average RR 0.61, 95% CI 0.47 to 0.78, 11 studies, 705 women, I² = 65%, very low-quality evidence). There was no clear difference between the groups in rates of bradycardia (RR 0.63, 95% CI 0.11 to 3.56, 1 study, 74 women, very low-quality evidence) or nausea and/or vomiting (average RR 0.42, 95% CI 0.14 to 1.27, 4 studies, 276 women, I² = 32%, very-low quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (130 babies, very low-quality evidence). Walking versus lying There was no clear difference between the groups for women with hypotension requiring treatment (RR 0.71, 95% CI 0.41 to 1.21, 1 study, 37 women, very low-quality evidence). Many included studies reported little to no information that would allow an assessment of their risk of bias, limiting our ability to draw meaningful conclusions. GRADE assessments of the quality of evidence ranged from very low to low. We downgraded evidence for limitations in study design, imprecision, and indirectness; most studies assessed only women scheduled for elective caesarean sections. External validity also needs consideration. Readers should question the use of colloids in this context given the serious potential side effects such as allergy and renal failure associated with their administration. AUTHORS' CONCLUSIONS: While interventions such as crystalloids, colloids, ephedrine, phenylephrine, ondansetron, or lower leg compression can reduce the incidence of hypotension, none have been shown to eliminate the need to treat maternal hypotension in some women. We cannot draw any conclusions regarding rare adverse effects associated with use of the interventions (for example colloids) due to the relatively small numbers of women studied.


Assuntos
Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Cesárea , Hipotensão/prevenção & controle , Complicações Intraoperatórias/prevenção & controle , Antieméticos/uso terapêutico , Coloides/uso terapêutico , Soluções Cristaloides/uso terapêutico , Efedrina/uso terapêutico , Feminino , Humanos , Hipotensão/induzido quimicamente , Soluções Isotônicas/uso terapêutico , Ondansetron/uso terapêutico , Fenilefrina/uso terapêutico , Náusea e Vômito Pós-Operatórios/tratamento farmacológico , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Vasoconstritores/uso terapêutico , Caminhada
11.
Ann Afr Med ; 19(2): 137-143, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32499471

RESUMO

Objective: Administration of warm intravenous (IV) fluid infusion and use of forced air warmers is the most easy and physiologically viable method for maintaining normothermia during surgery and postsurgical periods This study was conducted to assess the effect of combination of active warming (AW) methods namely warm IV fluid infusion and forced air warming versus forced air warming only (WA) on maternal temperature during elective C-delivery under spinal anesthesia. Materials and Methods: A total of 100 patients scheduled for elective c-section were grouped into those who received both warmed IV fluid infusion and forced air warmer (Combination of active warming WI= 50) and those who received only forced air warmer (WA = 50). Core body temperature and shivering incidence were recorded using a tympanic thermometer from prespinal till the end of surgery every 10 min and in postanesthesia care unit (PACU) at 0, 15, and 30 min. Results: Core temperature showed statistically significant difference in 15, 35, 45, and 55 min between air warmer and warm infusion groups and in PACU at 0, 15, and 30 min, it was statistically significant (P = 0.000) among WI group (mean temperature = 36.79°C) when compared to WA group (mean temperature = 35.96°C). There was a lower incidence of shivering in WI compared to WA group, which is statistically significant. Conclusion: Combination of warm Intravenous fluid infusion and Forced air warming is better than forced air warming alone. In maintaining near normal maternal core body temperature during elective cesarean section following spinal anesthesia. Combined warming method also reduces shivering incidence.


Assuntos
Anestesia Obstétrica/métodos , Raquianestesia/efeitos adversos , Cesárea/efeitos adversos , Temperatura Alta/uso terapêutico , Hipotermia/prevenção & controle , Infusões Intravenosas/métodos , Cuidados Intraoperatórios/métodos , Administração Intravenosa , Adulto , Período de Recuperação da Anestesia , Anestesia Obstétrica/efeitos adversos , Raquianestesia/métodos , Regulação da Temperatura Corporal , Cesárea/métodos , Feminino , Humanos , Hipotermia/induzido quimicamente , Hipotermia/etiologia , Monitorização Intraoperatória/métodos , Gravidez , Tremor por Sensação de Frio/efeitos dos fármacos , Tremor por Sensação de Frio/fisiologia , Fatores de Tempo , Resultado do Tratamento
12.
Arch Gynecol Obstet ; 302(4): 829-836, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32588134

RESUMO

OBJECTIVE: To investigate the efficacy and safety of prophylactic infusion of norepinephrine (NE) versus normal saline in patients undergoing cesarean section. METHODS: Patients (n = 97) were randomized to receive a bolus of NE (6 µg) immediately following spinal anesthesia with maintenance NE (0.05 µg/kg/min IV) or normal saline (n = 98). The primary endpoint was the incidence of postspinal anesthesia hypotension [systolic blood pressure (SBP) < 80% of baseline] at 1-20 min following spinal anesthesia. Secondary outcomes were the overall stability of SBP control versus baseline, inferior vena cava collapsibility index (IVC-CI), other adverse events (bradycardia, nausea, vomiting, and hypertension), and neonatal outcomes (blood gas values and Apgar scores). RESULTS: The rates of postspinal anesthesia hypotension and severe postspinal anesthesia hypotension (SBP < 60% of the baseline) were significantly lower in the NE group (17.5% vs. 62.2%, p < 0.001; 7.2% vs. 17.4%, p = 0.031). In the NE group, SBP remained more stable and closer to baseline (p < 0.001), and IVC-CI values were lower 5 min after spinal anesthesia and 5 min after fetal delivery (p = 0.045; p < 0.001, respectively). Other adverse effects and neonatal outcomes were not different between the two groups. CONCLUSION: Prophylactic NE infusion effectively lowers the incidence of postspinal anesthesia hypotension and does not increase other adverse events in patients or neonates.


Assuntos
Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Cesárea/efeitos adversos , Hipotensão/prevenção & controle , Infusões Parenterais/efeitos adversos , Norepinefrina/administração & dosagem , Profilaxia Pré-Exposição/métodos , Vasoconstritores/administração & dosagem , Adulto , Anestesia Obstétrica/métodos , Raquianestesia/métodos , Pressão Sanguínea , Bradicardia/induzido quimicamente , Bradicardia/epidemiologia , Cesárea/métodos , China/epidemiologia , Feminino , Humanos , Hipertensão/induzido quimicamente , Hipertensão/complicações , Hipotensão/epidemiologia , Recém-Nascido , Infusões Parenterais/métodos , Pessoa de Meia-Idade , Náusea/induzido quimicamente , Náusea/epidemiologia , Norepinefrina/efeitos adversos , Gravidez , Resultado do Tratamento , Vasoconstritores/efeitos adversos , Vômito/induzido quimicamente , Vômito/epidemiologia , Adulto Jovem
13.
Pol Merkur Lekarski ; 48(285): 215-220, 2020 Jun 17.
Artigo em Polonês | MEDLINE | ID: mdl-32564050

RESUMO

Demographic data clearly show the progressive aging of societies. Problems and specificity of anaesthesia in the elderly becomes a particularly important issue in this context. Spinal anesthesia is a method often used to anesthetize elderly patients, and hypotension is one of its most common early complications. Untreated or improperly treated hypotension increases the risk of perioperative complications such as myocardial infarction, ischemic stroke or acute renal failure. The prevention of hypotension consists of intravenous fluid therapy and pre-emptive use of vasoconstrictor drugs. Among vasoconstrictors, ephedrine and phenylephrine are commonly used to treat hypotension due to spinal anaesthesia. Both drugs are available in Poland. Issues related to their use in the treatment of hypotension caused by spinal anaesthesia in the elderly, including the features of both drugs, their method of administration and dosage based on the literature and own experience are the subject of this study. It should be noted, however, that most studies in the use of ephedrine and phenylephrine as a targeted treatment for hypotension concern the obstetric patient population while the elderly population is underrepresented and the results are inconclusive.


Assuntos
Anestesia , Hipotensão , Idoso , Anestesia/efeitos adversos , Anestesia Obstétrica/efeitos adversos , Cesárea , Feminino , Humanos , Hipotensão/etiologia , Fenilefrina , Polônia , Gravidez
15.
Anaesth Crit Care Pain Med ; 39(3): 345-349, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32405520
16.
Curr Opin Anaesthesiol ; 33(3): 291-298, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32371631

RESUMO

PURPOSE OF REVIEW: Hypotension during cesarean section remains a frequent complication of spinal anesthesia and is associated with adverse maternal and fetal events. RECENT FINDINGS: Despite ongoing research, no single measure for sufficient treatment of spinal-induced hypotension was identified so far. Current literature discusses the efficacy of low-dose spinal anesthesia, timing and solutions for adequate fluid therapy and various vasopressor regimens. Present guidelines favor the use of phenylephrine over ephedrine because of decreased umbilical cord pH values, while norepinephrine is discussed as a probable superior alternative with regard to maternal bradycardia, although supporting data is limited. Alternative pharmacological approaches, such as 5HT3-receptor antagonists and physical methods may be taken into consideration to further improve hemodynamic stability. SUMMARY: Current evidence favors a combined approach of low-dose spinal anesthesia, adequate fluid therapy and vasopressor support to address maternal spinal-induced hypotension. As none of the available vasopressors is associated with relevantly impaired maternal and fetal outcomes, none of them should be abandoned from obstetric practice. Rapid crystalloid co-loading is of equivalent efficacy as compared with colloids and should be preferred because of a more favorable risk profile.


Assuntos
Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Cesárea , Hipotensão/induzido quimicamente , Vasoconstritores/efeitos adversos , Feminino , Humanos , Doença Iatrogênica , Gravidez , Simpatectomia
17.
Br J Anaesth ; 125(1): e81-e87, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32303378

RESUMO

BACKGROUND: Pregnant women are at increased risk of hypoxaemia during general anaesthesia. Our aim was to determine the incidence and the risk factors that contribute to hypoxaemia in this setting. METHODS: Every woman 18 yr or older who underwent a non-elective Caesarean section under general anaesthesia was eligible to participate in this multicentre observational study. The primary endpoint was the incidence of hypoxaemia defined as the SpO2 ≤95%. The secondary endpoint was the incidence of difficult intubation defined as more than two attempts or failed intubation. RESULTS: During the study period, 895 women were prospectively included in 17 maternity hospitals, accounting for 79% of women who had general anaesthesia for non-elective Caesarean section. Maternal hypoxaemia was observed in 172 women (19%; confidence interval [CI], 17-22%). Risk factors associated with hypoxaemia in the multivariate analysis were difficult or failed intubation (adjusted odds ratio [aOR]=19.1 [8.6-42.7], P<0.0001) and BMI >35 kg m-2 (aOR=0.53 [0.28-0.998], P=0.0495). Intubation was difficult in 40 women (4.5%; CI, 3.3-6%) and failed intubation occurred in five women (0.56%; CI, 0.1-1%). In the multivariate analysis, use of a hypnotic drug other than propofol was associated with difficult or failed intubation (aOR=25 [2-391], P=0.02). A propensity score confirmed that propofol was associated with a significant decreased risk of difficulty or failure to intubate (P<0.001). CONCLUSIONS: Hypoxaemia during Caesarean sections was observed in 19% of women and was significantly associated with difficult or failed intubation. The use of propofol may protect against the occurrence of difficult intubation.


Assuntos
Anestesia Geral/efeitos adversos , Anestesia Obstétrica/efeitos adversos , Cesárea , Hipóxia/epidemiologia , Mães , Adulto , Anestesia Geral/métodos , Anestesia Obstétrica/métodos , Feminino , França/epidemiologia , Humanos , Incidência , Intubação Intratraqueal , Gravidez , Estudos Prospectivos , Fatores de Risco
19.
Anesth Analg ; 131(1): 307-316, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32149754

RESUMO

This article summarizes the Gerard W. Ostheimer Lecture given at the 2019 Society for Obstetric Anesthesia and Perinatology annual meeting. The article summarizes key articles published in 2018 that were presented in the 2019 Ostheimer Lecture, with a focus on maternal mortality, maternal complications, analgesic and anesthetic management of vaginal and cesarean deliveries, postpartum care, and the impact of anesthesia on maternal outcomes. The reviewed literature highlights many opportunities for anesthesiologists to impact maternal care and outcomes. The major themes presented in this manuscript are maternal mortality including amniotic fluid and cardiac arrest; postpartum hemorrhage; venous thromboembolism; management of spinal-induced hypotension; postpartum care including opioid use, postcesarean analgesia, and postpartum depression. A proposed list of action items and research topics based on the literature from 2018 is also presented. Specifically, anesthesiologists should use prophylactic vasopressor infusions during elective cesarean delivery; use a structured algorithm to diagnose pulmonary embolus, and reevaluate the use of D-dimer measurements; target postpartum opioid analgesia and prescribing; use multimodal postcesarean delivery analgesia, preferably with neuraxial hydrophilic opioids; and study any association between labor analgesia on postpartum depression.


Assuntos
Anestesia Obstétrica/tendências , Congressos como Assunto/tendências , Parto Obstétrico/tendências , Sociedades Médicas/tendências , Anestesia Obstétrica/efeitos adversos , Anestesia Obstétrica/métodos , Parto Obstétrico/efeitos adversos , Parto Obstétrico/métodos , Feminino , Humanos , Mortalidade Materna/tendências , Gravidez , Complicações na Gravidez/epidemiologia , Complicações na Gravidez/prevenção & controle
20.
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
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