Epidural hydroxyethyl starch ameliorating postdural puncture headache after accidental dural puncture / 中华医学杂志(英文版)

BACKGROUND@#No convincing modalities have been shown to completely prevent postdural puncture headache (PDPH) after accidental dural puncture (ADP) during obstetric epidural procedures. We aimed to evaluate the role of epidural administration of hydroxyethyl starch (HES) in preventing PDPH following ADP, regarding the prophylactic efficacy and side effects.@*METHODS@#Between January 2019 and February 2021, patients with a recognized ADP during epidural procedures for labor or cesarean delivery were retrospectively reviewed to evaluate the prophylactic strategies for the development of PDPH at a single tertiary hospital. The development of PDPH, severity and duration of headache, adverse events associated with prophylactic strategies, and hospital length of stay postpartum were reported.@*RESULTS@#A total of 105 patients experiencing ADP received a re-sited epidural catheter. For PDPH prophylaxis, 46 patients solely received epidural analgesia, 25 patients were administered epidural HES on epidural analgesia, and 34 patients received two doses of epidural HES on and after epidural analgesia, respectively. A significant difference was observed in the incidence of PDPH across the groups (epidural analgesia alone, 31 [67.4%]; HES-Epidural analgesia, ten [40.0%]; HES-Epidural analgesia-HES, five [14.7%]; P <0.001). No neurologic deficits, including paresthesias and motor deficits related to prophylactic strategies, were reported from at least 2 months to up to more than 2 years after delivery. An overall backache rate related to HES administration was 10%. The multivariable regression analysis revealed that the HES-Epidural analgesia-HES strategy was significantly associated with reduced risk of PDPH following ADP (OR = 0.030, 95% confidence interval: 0.006-0.143; P < 0.001).@*CONCLUSIONS@#The incorporated prophylactic strategy was associated with a great decrease in the risk of PDPH following obstetric ADP. This strategy consisted of re-siting an epidural catheter with continuous epidural analgesia and two doses of epidural HES, respectively, on and after epidural analgesia. The efficacy and safety profiles of this strategy have to be investigated further.

Intermittent loss of consciousness during cesarean section under spinal anesthesia: a case report / Perda intermitente de consciência durante cesariana sob raquianestesia: relato de caso

Abstract Loss of consciousness during spinal anesthesia is a rare but scary complication. This complication is generally related to severe hypotension and bradycardia, but in this case, the loss of consciousness occurred in a hemodynamically stable parturient patient. We present a 31 years-old patient who underwent an emergency cesarean section. She lost consciousness and had apnea that started 10 minutes after successful spinal anesthesia and repeated three times for a total of 25 minutes, despite the stable hemodynamics of the patient. The case was considered a subdural block, and the patient was provided with respiratory support. The subdural block is expected to start slowly (approximately 15-20 minutes), but in this case, after about 10 minutes of receiving anesthesia, the patient suddenly had a loss of consciousness. After the recovery of consciousness and return of spontaneous respiration, the level of a sensory block of the patient, who was cooperative and oriented, was T4. There were motor blocks in both lower extremities. Four hours after intrathecal injection, both the sensory and motor blocks ended, and she was discharged two days later with no complications. Hence, patients who receive spinal anesthesia should be closely observed for any such undesirable complications.

Resumo A perda de consciência durante a raquianestesia é uma complicação rara, mas assustadora. Essa complicação geralmente está relacionada à grave hipotensão e bradicardia, mas, neste caso, a perda de consciência ocorreu em uma paciente parturiente hemodinamicamente estável. Apresentamos o caso de uma paciente de 31 anos, submetida a uma cesariana de emergência. A paciente perdeu a consciência e apresentou apneia que teve início 10 minutos após a raquianestesia bem-sucedida e repetiu o episódio três vezes por 25 minutos, a despeito de sua hemodinâmica estável. O caso foi considerado como um bloqueio subdural e a paciente recebeu suporte respiratório. Espera-se que o bloqueio subdural inicie lentamente (aproximadamente 15-20 minutos), mas, neste caso, cerca de 10 minutos após a anestesia, a paciente repentinamente perdeu a consciência. Após a recuperação da consciência e o retorno da respiração espontânea, a paciente que estava orientada e cooperativa apresentou nível de bloqueio sensorial em T4. Havia bloqueio motor em ambas as extremidades inferiores. O bloqueio sensório-motor terminou quatro horas após a injeção intratecal e a paciente recebeu alta hospitalar dois dias depois, sem complicações. Considerando o exposto, os pacientes que recebem raquianestesia devem ser atentamente observados para quaisquer complicações indesejáveis.

The effects of crystalloid warming on maternal body temperature and fetal outcomes: a randomized controlled trial / Os efeitos do aquecimento de cristaloides sobre a temperatura corporal materna e nas condições fetais: ensaio clínico randômico

Abstract Background and objectives: Hypothermia occurs in about 60% of patients under anesthesia and is generally not managed properly during short lasting surgical procedures. Hypothermia is associated with adverse clinical outcomes. The current study is designed to assess the effects of crystalloid warming on maternal and fetal outcomes in patients undergoing elective cesarean section with spinal anesthesia. Methods: In this prospective randomized controlled trial, sixty parturients scheduled for elective cesarean section with spinal anesthesia were randomly allocated to receive crystalloid at room temperature or warmed at 37 °C. Spinal anesthesia was performed at L3-L4 interspace with 10 mg of hyperbaric bupivacaine without adding opioids. Core temperature, shivering, and hemodynamic parameters were measured every minute until 10th minute and 5-min intervals until the end of operation. The primary outcome was maternal core temperature at the end of cesarean section. Results: There was no difference for baseline tympanic temperature measurements but the difference was significant at the end of the operation (p = 0.004). Core temperature was 36.8 ± 0.5 °C at baseline and decreased to 36.3 ± 0.5 °C for isothermic warmed crystalloid group and baseline tympanic core temperature was 36.9 ± 0.4 °C and decreased to 35.8 ± 0.7 °C for room temperature group at the end of the operation. Shivering was observed in 43.3% in the control group. Hemodynamic parameter changes and demographic data were not significant between groups. Conclusions: Isothermic warming crystalloid prevents the decrease in core temperature during cesarean section with spinal anesthesia in full-term parturients. Fetal Apgar scores at first and fifth minute are higher with isothermic warming.

Resumo Justificativa e objetivos: A hipotermia ocorre em cerca de 60% dos pacientes sob anestesia e geralmente não é tratada adequadamente durante procedimentos cirúrgicos de curta duração. A hipotermia está associada a desfechos clínicos adversos. O presente estudo teve como objetivo avaliar os efeitos do aquecimento de cristaloides nas condições maternas e fetais em pacientes submetidas à cesariana eletiva com raquianestesia. Métodos: Neste estudo prospectivo, randômico e controlado, 60 parturientes agendadas para cesárea eletiva com raquianestesia foram distribuídas aleatoriamente para receber cristaloides à temperatura ambiente ou aquecidos a 37 °C. A raquianestesia foi realizada no interespaço L3-L4 com 10 mg de bupivacaína hiperbárica sem adição de opioides. Temperatura central, tremores e parâmetros hemodinâmicos foram medidos a cada minuto até o décimo minuto e em intervalos de 5 min até o fim da operação. O desfecho primário foi a temperatura central materna ao final da cesárea. Resultados: Não houve diferença nas mensurações basais da temperatura timpânica, mas a diferença foi significativa no fim da operação (p = 0,004). A temperatura central foi de 36,8 ± 0,5 °C na fase basal e diminuiu para 36,3 ± 0,5 °C no grupo com aquecimento isotérmico de cristaloides e a temperatura basal timpânica foi de 36,9 ± 0,4 °C e diminuiu para 35,8 ± 0,7 °C no grupo sem aquecimento das soluções no fim da operação. Tremores foram observados em 43,3% no grupo controle. Alterações nos parâmetros hemodinâmicos e dados demográficos não foram significantes entre os grupos. Conclusões: O aquecimento isotérmico de cristaloides previne a redução da temperatura central durante a cesariana com raquianestesia em parturientes a termo. Os escores de Apgar para os fetos no primeiro e quinto minutos são maiores com o aquecimento isotérmico.

Cefalea post punción dural en embarazadas sometidas a cesárea con anestesia raquidea ¿problema actual o pasado? / Cefalea post dural puncture in pregnant submissions to caesárea with raquidea anesthesia problem current or past?

Objetivos: Conocer la incidencia de cefaleas postpunción dural (CPPD) en raquianestesia para cesárea y factores de riesgo reconocidos. Efectividad del tratamiento médico y necesidad de parche hemático peridural. Metodología: Estudio prospectivo, descriptivo, con seguimiento postoperatorio por 72 horas de 914 embarazadas que recibieron raquianestesia para cesárea en el Hospital de la Mujer durante 1 año. Datos registrados por anestesiólogo actuante, seguimiento por un residente. Al diagnosticar una CPPD, se instaló tratamiento según protocolo. Resultados: la incidencia de CPPD fue 2,6 casos/ 100 pacientes, 24 en la población estudiada. 66.7%, aparecieron a las 24 horas; 16,7% a las 48 horas. 54,2% mejoraron a las 24 horas, ninguna requirió parche hemático. 86,3% de las punciones fueron con agujan 25 punta de lápiz, 11,2% con 27 punta de lápiz 23 casos de CPPD para la primera y 1 caso para la segunda, no encontrando asociación estadística (p= 0,759). 76,6% fueron punción única, 15,2% 2 punciones, 7% más de 2. 80,7 % cesáreas urgencia, 65,2% en horario diurno. 42% realizadas por anestesiólogos, 54% por residentes. 8,6% tenían antecedente de cefalea y 2,7% antecedente de CPPD; encontrándose asociación estadística entre la primera y CPPD actual (p=0,001) y entre la segunda y la presencia de CPPD (p=0,004). Conclusiones: obtuvimos una incidencia de CPPD de 2,6%, concordante con datos de la literatura; la mayoría apareció a las 24 horas y todas mejoraron con tratamiento médico. Las pacientes con cefalea y CPPD previa presentaron un RR 5,8 y 5,4 respectivamente (IC 95%), no encontrando asociación con otros factores de riesgo.

Objectives: To know the incidence of post-dural puncture headaches (CPPD) in spinal anesthesia for caesarean section and recognized risk factors. Effectiveness of medical treatment and need for an epidural blood patch Methodology: Prospective, descriptive, postoperative follow-up for 72 hours of 914 pregnant women who received spinal anesthesia for cesarean section, Women 's Hospital during one year study. Data recorded by acting anesthesiologist monitoring by a resident. CPPD to diagnose, treatment was installed according to protocol. Results: CPPD incidence was 2.6 cases / 100 patients, 24 in the study population. 66.7% appeared at 24 hours; 16.7% at 48 hours. 54.2% improved within 24 hours, none required blood patch. 86.3% of punctures were 25G tip pen, 11.2% with 27G tip pen, 23 cases of CPPD for the first and 1 case for the second, finding no statistical association (p = 0.759). 76.6% were single puncture, 15.2% two punctures, 7% more than two. 80.7% cesarean urgency, 65.2% in daytime. 42% made by anesthesiologists, 54% by residents. 8.6% had a history of headache and 2.7% history of CPPD; statistical association was found between the first and current CPPD (p = 0.001) and between the second and the presence of CPPD (p = 0.004). Conclusions: We obtained a CPPD incidence of 2.6%, consistent with data from the literature; Most appeared within 24 hours and all improved with medical treatment. Patients with headache and previous PDCH presented RR 5.8 and 5.4 respectively (95% CI), and found no association with other risk factors.

Life-threatening acute subdural haematoma after combined spinal-epidural anaesthesia in labour / Hematoma subdural agudo potencialmente fatal após anestesia combinada raqui-peridural em parto

ABSTRACTBACKGROUND AND OBJECTIVES: Only few reports in literature have pointed out to the possibility of a cranial subdural haematoma formation associated with dural puncture during spinal or epidural analgesia. We herein describe such a rare case who was diagnosed to have acute subdural haematoma after combined spinal-epidural anaesthesia used in labour.CASE REPORT: A 34-year-old, primigravid women with a gestation of 38 weeks underwent caesarean section under combined spinal-epidural anaesthesia and gave birth to a healthy boy. Thirty-two hours after delivery, her moderate headache progressed to a severe headache associated with nausea and vomiting and later was more complicated with a generalized tonic-clonic seizure and ensuing lethargy. Computed tomography of the brain demonstrated a right-sided fronto-temporo-parietal acute subdural haematoma with diffuse cerebral oedema. She underwent urgent FTP craniotomy and evacuation of the haematoma. Early postoperative cranial computed tomography showed a clean operative site. Eight days after subdural haematoma surgery, she became lethargic again, and this time cranial computed tomography disclosed an extradural haematoma under the bone flap for which she had to undergo surgery again. Two days later, she was discharged home with Karnofsky performance score of 90/100. At follow-up exam, she was neurologically intact and her cranial computed tomography and magnetic resonance were normal.CONCLUSIONS: As conclusion, with the use of this combined spinal-epidural anaesthesia, it should be kept in mind that headache does not always mean low pressure headache associated with spinal anaesthesia and that a catastrophic complication of subdural haematoma may also occur.

RESUMOJUSTIFICATIVA E OBJETIVOS: Apenas alguns relatos na literatura mencionaram a possibilidade de formação de hematoma subdural craniano associada à punção durante a raquianestesia ou anestesia epidural. O presente relato descreve um caso tão raro que foi diagnosticado como hematoma subdural agudo após anestesia combinada raqui-peridural usada em parto.RELATO DE CASO: Paciente primípara, 34 anos, com 38 semanas de gestação, submetida à cesariana sob anestesia combinada raqui-peridural, deu à luz um menino saudável. Após 32 horas do parto, a dor de cabeça moderada da paciente progrediu para dor de cabeça intensa associada a náusea e vômito e se complicou subsequentemente com crise convulsiva generalizada tônico-clônica e consequente letargia. Tomografia computadorizada do cérebro revelou hematoma subdural agudo do lado direito em região frontotemporoparietal (FTP) com edema cerebral difuso. A paciente foi submetida à craniotomia FTP de urgência e evacuação do hematoma. Tomografia computadorizada do crânio no pós-operatório precoce mostrou um sítio operatório limpo. Oito dias após a cirurgia do hematoma subdural, a paciente voltou a ficar letárgica e, dessa vez, a tomografia computadorizada revelou um hematoma extradural sob o retalho ósseo que exigiu outra cirurgia. Dois dias depois, a paciente recebeu alta hospitalar com classificação de desempenho Karnofsky de 90/100. Ao exame de acompanhamento, a paciente apresentou-se neurologicamente intacta e sua tomografia computadorizada e ressonância magnética estavam normais.CONCLUSÃO: Ao usar a anestesia combinada raqui-peridural deve-se ter em mente que dor de cabeça nem sempre significa dor de cabeça hipotensiva associada à raquianestesia e que uma complicação catastrófica de hematoma subdural também pode ocorrer.

Comparison of droperidol and ondansetron prophylactic effect on subarachnoid morphine-induced pruritus / Comparação dos efeitos profiláticos do droperidol e do ondansetron sobre o prurido provocado pela morfina subaracnoidea / Comparación de los efectos profilácticos del droperidol y del ondansetrón sobre el prurito provocado por la morfina subaracnoidea

The prophylactic effect of ondansetron on subarachnoid morphine-induced pruritus is controversial, while evidence suggests that droperidol prevents pruritus. The aim of this study is to compare the effects of droperidol and ondansetron on subarachnoid morphine-induced pruritus.

O efeito profilático do ondansetron sobre prurido provocado pela morfina subaracnoidea é controverso, enquanto evidências sugerem que o droperidol previne o prurido. O objetivo do presente trabalho é comparar o efeito do droperidol com o do ondansetron sobre o prurido provocado pela morfina subaracnoidea.

El efecto profiláctico del ondansetrón sobre el prurito provocado por la morfina subaracnoidea es controvertido, mientras las evidencias nos muestran que el droperidol previene el prurito. El objetivo del presente trabajo es comparar el efecto del droperidol con el del ondansetrón sobre el prurito provocado por la morfina subaracnoidea.

Incidência de tremores após cesarianas sob raquianestesia com ou sem sufentanil intratecal: estudo aleatório / Incidence of shivering after cesarean section under spinal anesthesia with or without intrathecal sufentanil: a randomized study / Incidencia de temblores después de cesáreas bajo raquianestesia con o sin sufentanilo intratecal: estudio randomizado

JUSTIFICATIVA E OBJETIVO: Tremores são causa de desconforto e insatisfação das pacientes submetidas à cesariana. O objetivo deste estudo foi analisar o impacto do uso de sufentanil intratecal na incidência de tremores após cesarianas. PACIENTES E MÉTODOS: Em um ensaio clínico prospectivo aleatório encoberto, foram incluídas no estudo gestantes submetidas à cesariana sob raquianestesia. Foram excluídas as gestantes em trabalho de parto, febris, obesas, com doença hipertensiva da gravidez, com falha do bloqueio anestésico ou complicação cirúrgica. As pacientes foram distribuídas aleatoriamente em dois grupos. No Grupo I foram administrados 10 mg de bupivacaína 0,5% hiperbárica associados a 80 mcg de morfina e 2,5 mcg de sufentanil. No Grupo II foram administrados 10 mg de bupivacaína 0,5% hiperbárica associados a 80 mcg de morfina. Na Sala de Recuperação Pós-Anestésica as pacientes foram avaliadas quanto à presença de sinais de tremores por observador que desconhecia o grupo ao qual a paciente havia sido alocada. RESULTADOS: A amostra constou de 80 pacientes. Em ambos os grupos houve diminuição na temperatura axilar das pacientes após a cesariana (p < 0,001). Essa diminuição não se mostrou diferente entre os grupos (p < 0,21). No Grupo I a incidência de tremores foi de 13/40 (32,5%) pacientes e no Grupo II foi de 25/40 (62,5%) (p < 0,007) - Risco Relativo 0,53 (IC 95% 0,32-0,87). CONCLUSÕES: Sugere-se que a adição de sufentanil à bupivacaína hiperbárica e morfina durante raquianestesia para cesariana proporciona diminuição na incidência de tremores no período pós-operatório imediato.

BACKGROUND AND OBJECTIVES: Shivering is a cause of discomfort and dissatisfaction in patients undergoing cesarean section. The objective of this study paper was to assess the impact of intrathecal administration of sufentanil on the incidence of shivering after cesarean section. METHOD: In a prospective blinded, randomized clinical trial, pregnant women undergoing cesarean section under spinal anesthesia were enrolled. Pregnant women in labor, febrile, obese, with pregnancy-induced hypertension, anesthetic block failure or surgical complications were excluded. Patients were randomly assigned to two groups. In Group I, 10 mg of 0.5% hyperbaric bupivacaine combined with 80 mcg of morphine and 2.5 mcg of sufentanil were administered. In Group II, 10 mg of 0.5% hyperbaric bupivacaine combined with 80 mcg of morphine were administered. In the post-anesthesia care unit, patients were evaluated for signs of shivering by an investigator blinded to the patient's group allocation. RESULTS: The sample consisted of 80 patients. In both groups there was a decrease in axillary temperature of patients after cesarean section (p < 0.001). This decrease was not different between groups (p < 0.21). In Group I, the incidence of tremor was 32.5% (13/40) and in Group II it was 62.5% (25/40) (p < 0.007); RR 0.53 (CI 95% 0.32-0.87). CONCLUSIONS: It has been suggested that the addition of sufentanil to hyperbaric bupivacaine and morphine during spinal anesthesia for cesarean section provides a decrease in the incidence of shivering in the immediate postoperative period.

JUSTIFICATIVA Y OBJETIVOS: Los temblores son provenientes de la incomodidad y de la insatisfacción de las pacientes sometidas a la cesárea. El objetivo de este estudio, fue analizar el impacto del uso de sufentanilo intratecal en la incidencia de temblores posteriores a las cesáreas. PACIENTES Y MÉTODOS: En un ensayo clínico prospectivo randomizado encubierto, se incluyeron en el estudio embarazadas sometidas a la cesárea bajo raquianestesia. Se excluyeron las embarazadas en trabajo de parto, febriles, obesas, con enfermedad hipertensiva del embarazo, con fallo en el bloqueo anestésico o complicación quirúrgica. Las pacientes se distribuyeron aleatoriamente en dos grupos. En el Grupo I, fueron administrados 10 mg de bupivacaína al 0,5% hiperbárica asociados a 80 mcg de morfina y 2,5 mcg de sufentanilo. En el Grupo II, fueron administrados 10 mg de bupivacaína al 0,5% hiperbárica asociados a 80 mcg de morfina. En la Sala de Recuperación Postanestésica, las pacientes se evaluaron en cuanto a la presencia de signos de temblores por un observador que no conocía el grupo en el cual la paciente había sido ubicada. RESULTADOS: La muestra constó de 80 pacientes. En los dos grupos se produjo una reducción en la temperatura axilar de las pacientes después de la cesárea (p < 0,001). Esa disminución no fue diferente entre los grupos (p < 0,21). En el Grupo I la incidencia de temblores fue de 13/40 (32,5%) pacientes y en el Grupo II de 25/40 (62,5%) (p < 0,007) - Riesgo Relativo 0,53 (IC 95% 0,32-0,87). CONCLUSIONES: Sugerimos que la adición de sufentanilo a la bupivacaína hiperbárica y morfina durante la raquianestesia para la cesárea, proporciona la disminución en la incidencia de temblores en el período postoperatorio inmediato.

Cefalea pospunción dural en la paciente obstétrica / Headache after a dural puncture in obstetric patient

La punción lumbar o dural (PL), consiste en pasar una aguja a través de la duramadre hasta el espacio subaracnoideo, el cual está lleno de líquido cefalorraquídeo (LCR). Siempre que la dura madre o la aracnoides sean puncionadas, los pacientes están en riesgo de desarrollar cefalea pospunción dural. El objetivo de este estudio fue hacer una puesta al día sobre las causas, diagnóstico, prevención y tratamiento de la cefalea pospunción dural. La cefalea pospunción dural (CPPD) se comporta como un dolor de cabeza bilateral que se desarrolla dentro de los 5 días posteriores a la realización de PL y desaparece en una semana...

The lumbar puncture (LP) or dural puncture consist of to pass a needle through the dura mater until the subarachnoid space, which is full of cerebrospinal fluid (CSF). Whenever the dura mater or the arachnoid be punctured, the patients are in risk of to develop headache post dural puncture (HPDP). The aim of present study was to update on the causes, diagnosis, prevention and treatment of this type of puncture. The HPDP behaves likes a bilateral headache developed at 5 days post lumbar puncture and disappear at a week...

PDPH by using gauge of needles

There is increase incidence of Lower Segment Caesarean section [LSCS] being performed under sub-arachnoid block [SAB] because it is relatively safe. One of the complications of SAB is Post Dural Puncture Headache [PDPH] which is very distressing to the patient. To observe the incidence of PDPH by using two different types of spinal needle of 25 gauge in females undergoing LSCS under SAB. Currently, in our setup 25G cutting [quincke] spinal needle is routinely used. Randomized controlled trial. Department of Anesthesia, Officers Family Hospital, Rawalpindi Cantt. 6 months from 15 February 2011 to 15 July 2011. 100 pregnant patients undergoing elective CD under spinal anaesthesia were randomized into two group A and B. Group A received SAB with 25G Quincke needle; Group B-received SAB with 25G pencil-point needle. Follow up was done up to 72 hours after the surgery. Data obtained through study was analysed through computer software SPSS version 12. quantitative variables like age, weight and height are presented as mean and standard deviation. The frequency of PDPH was qualitatively analysed in percentage. The frequency of PDPH was compared between two groups with the application of Chi-square as test of significance at P-value <0.05. It was found that the incidence of PDPH with Quincke [cutting tip] needle was significantly higher [7.%] as compared to pencil point needle [0%]. Pencil-point needle is associated with lesser incidence of PDPH and should be preferred to Quincke needle to achieve SAB in patients undergoing LSCS

Unusual case of persistent Horner's syndrome following epidural anaesthesia and caesarean section.

This is a rare case of persistent Horner's syndrome following epidural anesthesia and Caesarean section. A 33-year-old female presented with persistent ptosis and miosis following epidural anesthesia and Caesarian section several months prior. Magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) of head, neck, and chest were unremarkable. Medline search using terms Horner’s, epidural, spinal anesthesia, delivery, childbirth, Caesarian, and pregnancy identified 31 articles describing Horner's syndrome in obstetric epidural anesthesia, of which 11 were following Caesarean section. The increased incidence of Horner's syndrome in the setting of epidural anesthesia in pregnancy may be related to epidural venous engorgement and cephalic spread of the local anaesthetic, with disruption in the oculosympathetic pathway. It is important to include recent epidural anesthesia within the differential diagnosis of acute Horner's syndrome in a postpartum female. Rarely, the ptosis may be permanent and require surgical intervention.

Anestesia regional para cesariana em gestantes obesas: estudo retrospectivo / Regional anesthesia for cesarean section in obese pregnant women: a retrospective study / Anestesia regional para cesárea en embarazadas obesas: estudio retrospectivo

JUSTIFICATIVA E OBJETIVOS: O levantamento dos dados teve por objetivo identificar as técnicas anestésicas, suas dificuldades e complicações em pacientes com IMC > 30 kg.m-2 submetidas à cesariana. Este levantamento de dados justifica-se por embasar o desenvolvimento de novos protocolos e condutas mais adequadas a essa população de gestantes. MÉTODO: Estudo retrospectivo de levantamento de dados e complicações anestésicas em pacientes obesas, maiores de 18 anos, submetidas à cesariana no período de janeiro de 2004 a dezembro de 2006. As variáreis avaliadas foram: idade, peso, altura, IMC, estado físico (ASA), técnicas anestésicas, dificuldades na palpação e punção, complicações hemodinâmicas (sangramento e hipotensão) e complicações anestésicas. RESULTADOS: Foram avaliadas 315 fichas anestésicas. A média de idade foi de 29,1 anos, o IMC médio foi de 39,25 e a maioria das pacientes foi classificada como ASA II (63,2 por cento). A técnica anestésica mais utilizada foi raquianestesia. Em 47 procedimentos, havia descrição de dificuldade de punção e, em 31 casos, dificuldade de palpação. CONCLUSÕES: As dificuldades técnicas encontradas foram mais acentuadas em pacientes de classes mais elevadas de obesidade, assim como hipotensão, sangramento e tempo cirúrgico.

BACKGROUND AND OBJECTIVES: The objective of the data gathering was to indentify anesthetic techniques, and their difficulties and complications in patients with BMI > 30 kg.m-2 undergoing cesarean sections. The study intends to support the development of new protocols and more adequate conducts for this population of pregnant women. METHODS: This is a retrospective study of data and anesthetic complications in obese patients older than 18 years of age who underwent cesarean sections from January 2004 to December 2006; variables investigated included: age, weight, height, BMI, physical status (ASA), anesthetic techniques, difficulties in palpation and puncturing, hemodynamic complications (bleeding and hypotension), and anesthetic complications. RESULTS: Three hundred and fifteen anesthetic forms were evaluated. Mean age was 29.1 years, mean BMI 39.25, and the majority of patients was classified as ASA II (63.2 percent). Spinal anesthesia charts used more often, difficulty to puncture was reported in 47 procedures, and difficulty to palpate was reported in 31 procedures. CONCLUSIONS: Technical difficulties as well as hypotension, bleeding, and surgical time were more frequent in patients with higher degrees of obesity.

JUSTIFICATIVA Y OBJETIVOS: La investigación de los datos tuvo el objetivo de identificar las técnicas anestésicas, sus dificultades y complicaciones en pacientes con IMC > = 30 kg.m-2, sometidas a la cesárea. Esa investigación se justifica porque tiene como base el desarrollo de nuevos protocolos y de conductas más adecuadas para esa población de embarazadas. MÉTODO: Estudio retrospectivo de investigación de datos y complicaciones anestésicas en pacientes obesas, mayores de 18 años y sometidas a la cesárea durante el período de enero de 2004 a diciembre de 2006. Las variables evaluadas fueron: edad, peso, altura, IMC, estado físico (ASA), técnicas anestésicas, dificultades en la palpación y punción, complicaciones hemodinámicas (sangramiento e hipotensión) y complicaciones anestésicas. RESULTADOS: Se evaluaron 315 fichas anestésicas. El promedio de edad fue de 29,1 años, el IMC promedio fue de 39,25 y la mayoría de las pacientes se clasificaron como ASA II (63,2 por ciento). La técnica anestésica más utilizada fue la raquianestesia. En 47 procedimientos se registró la dificultad de punción y en 31 casos dificultad de palpación. CONCLUSIONES: Las dificultades técnicas encontradas fueron más profundas en pacientes con clase más alta de obesidad, como también hipotensión, sangramiento y tiempo de quirófano.

Correlação entre o índice de massa corporal (IMC) de gestantes e hipotensão após raquianestesia para cesarianas / Correlation between the body mass index (BMI) of pregnant women and the development of hypotension after spinal anesthesia for cesarean section / Correlación entre el índice de masa corporal (IMC) de embarazadas e hipotensión después de la raquianestesia para cesáreas

JUSTIFICATIVA E OBJETIVOS: Existem poucas publicações correlacionando hipotensão em gestantes obesas, principalmente em obesas mórbidas, após raquianestesia para cesárea. Objetivamos avaliar a incidência de hipotensão correlacionada ao IMC. MÉTODO: No grupo Eutrofia foram incluídas 49 pacientes com IMC pré-gestacional abaixo de 25 kg.m-2 e no grupo Sobrepeso, 51 pacientes com IMC igual ou acima de 25 kg.m-2. Após raquianestesia, foram anotadas as medidas de pressão arterial, volume de cristaloides infundidos e dose de vasopressores utilizada até o nascimento. Redução da pressão arterial sistólica abaixo de 100 mmHg ou 10 por cento da pressão arterial sistólica (PAS) inicial foi classificada como hipotensão e corrigida com vasopressor. RESULTADOS: Os episódios de hipotensão foram menores no grupo Eutrofia (5,89 ± 0,53 vs. 7,80 ± 0,66; p = 0,027), assim como a quantidade de cristaloides (1.298 ± 413,6 mL vs. 1.539 ± 460,0 mL; p = 0,007) e o uso de vasopressores (5,87 ± 3,45 bolus vs. 7,70 ± 4,46 bolus; p = 0,023). Quanto às doenças associadas, observamos maior incidência de diabetes entre as gestantes obesas (29,41 por cento vs. 9,76 por cento, RR 1,60; IC 95 por cento: 1,15-2,22; p = 0,036), porém não houve diferença entre os grupos em relação à incidência de doença hipertensiva específica da gestação (DHEG) (sobrepeso: 21,57 por cento, peso normal: 12,20 por cento, RR 1,30; IC 95 por cento: 0,88-1,94; p = 0,28). CONCLUSÕES: Na amostra estudada, IMC pré-gestacional maior ou igual a 25 kg.m-2 apresentou-se como fator de risco para hipotensão após raquianestesia em pacientes submetidas a cesáreas. O mesmo grupo de pacientes necessitou de um número de doses maior de vasopressores. A valorização desses achados implica aprimorar as técnicas anestésicas nessas pacientes a fim de diminuir as consequências da hipotensão pós-raquianestesia, tanto na gestante como no feto.

BACKGROUND AND OBJECTIVES: Very few publications correlate hypotension in obese pregnant women, and especially morbidly obese, after spinal anesthesia for cesarean section. The objective of the present study was to evaluate the incidence of hypotension according to the BMI. METHODS: Forty-nine patients with pregestational BMI below 25 kg.m-2 were included in the Eutrophia group, and 51 patients with BMI > 25 kg.m-2 were included in the Overweight group. After spinal anesthesia, blood pressure, volume of crystalloid infused, and dose of vasopressors used until delivery were recorded. A fall in systolic blood pressure below 100 mmHg or 10 percent reduction of the initial systolic blood pressure (SBP) was considered as hypotension and it was corrected by the administration of vasopressors. RESULTS: Episodes of hypotension were fewer in the Eutrophia group (5.89 ± 0.53 vs. 7.80 ± 0.66, p = 0.027), as well as the amount of crystalloid administered (1,298 ± 413.6 mL vs. 1,539 ± 460.0 mL; p = 0.007), and use of vasopressors (5.87 ± 3.45 bolus vs. 7.70 ± 4.46 bolus; p = 0.023). As for associated diseases, we observed higher incidence of diabetes among obese pregnant women (29.41 percent vs. 9.76 percent, RR 1.60, 95 percentCI: 1.15-2.22, p = 0.036), however, differences in the incidence of pregnancy-induced hypertension (PIH) were not observe between both groups (overweight: 21.57 percent, normal weight: 12.20 percent, RR 1.30, 95 percentCI: 0.88-1.94, p = 0.28). CONCLUSIONS: In the study sample, pregestational BMI > 25 kg.m-2 was a risk factor for hypotension after spinal anesthesia in patients undergoing cesarean section. The same group of patients required higher doses of vasopressors. Those results indicate that the anesthetic techniques in those patients should be improved to reduce the consequences of post-spinal anesthesia hypotension, both in pregnant women and fetuses.

JUSTIFICATIVA Y OBJETIVOS: Existen pocas publicaciones correlacionando la hipotensión en embarazadas obesas y principalmente obesas mórbidas, después de la raquianestesia para cesárea. Deseamos aquí evaluar la incidencia de la hipotensión correlacionada con el IMC. MÉTODO: En el grupo Eutrofia fueron incluidas 49 pacientes con IMC pregestacional por debajo de 25 kg.m-2 y en el grupo Sobrepeso 51 pacientes con IMC igual o por encima de 25 kg.m-2. Después de la raquianestesia fueron anotadas las medidas de presión arterial, volumen de cristaloides infundidos y dosis de vasopresores utilizadas hasta el nacimiento. La reducción de la presión arterial sistólica por debajo de 100 mmHg o 10 por ciento de la presión arterial sistólica (PAS) inicial, fue considerado como hipotensión y corregida con vasopresor. RESULTADOS: Los episodios de hipotensión fueron menores en el grupo Eutrofia (5,89 ± 0,53 vs 7,80 ± 0,66; p 0,027); como también la cantidad de cristaloides (1298 ± 413,6 mL vs. 1539 ± 460,0 mL; p 0,007) y el uso de vasopresores (5,87 ± 3,45 bolo vs. 7,70 ± 4,46 bolo; p 0,023). En lo concerniente a las enfermedades asociadas, observamos una mayor incidencia de diabetes entre las embarazadas obesas (29,41 por ciento vs. 9,76 por ciento, RR 1,60, IC 95 por ciento: 1,15-2,22, p 0,036), pero no hubo una diferencia entre los grupos con relación a la incidencia de enfermedad hipertensiva específica de la gestación (DHEG) (sobrepeso: 21,57 por ciento, peso normal: 12,20 por ciento, RR 1,30, IC 95 por ciento: 0,88-1,94, p 0,28). CONCLUSIONES: En la muestra en estudio, el IMC pregestacional mayor o igual a 25 kg.m-2 se presentó como un factor de riesgo para la hipotensión después de la raquianestesia en pacientes sometidas a la cesárea. El mismo grupo de pacientes necesitó un número de dosis mayor de vasopresores. La valoración de esos hallazgos nos hace perfeccionar las técnicas anestésicas en esas pacientes para reducir las consecuencias de la hipotensión postraquianestesia, tanto en la embarazada como en el feto.

Spinal anaesthesia for cesarean delivery; study of different doses of IV ephedrine as prophylaxis to prevent hypotension during

To determine the effective dose of intravenous ephedrine for the prevention of hypotension during spinal anesthesia for cesarean delivery. A randomized, double-blinded dose finding study. The study was carried out in Combined Military Hospital Gujranwala from March 2009 to March 2010. Total patients were 80 full term women who were randomly allocated into four groups and were given Ringer lactate 10 ml per kg body weight intravenously. One minute after the spinal injection, patients were given saline control or ephedrine 0.1 mg per kg body weight, 0.25mg per kg body weight, or 0.4mg per kg body weight for 30 seconds. The study period started at the time of spinal injection and continued for 15 minutes. Systolic arterial pressure and heart rate were recorded at 1 -min intervals. Side effects like hypotension, hypertension, tachycardia, bradycardia, nausea and vomiting were also recorded. Total rescue ephedrine and total dose of used ephedrine in all groups were measured. Neonates were assessed by APGAR score. There was less incidence of hypotension in the ephedrine 0.4mg per kg body weight and 0.25 mg per kg body weight group as compared with ephedrine 0.1 mg per kg body weight and the control group, 5[25%], 13[65%] vs. 16[80%], 18 [90%] respectively. Systolic arterial pressure [SAP] in the first 15 min after the spinal injection was statistically significant greater in the 0.4mg per kg body weight group compared with other groups [P <0.001]. Reactive hypertension occurred in 9[45%] in the 0.4mg per kg group, compared with control group, 0[0%], ephedrine 0.1 mg, 1[5%] and ephedrine 0.25 mg 3[15%] patients. The Heart rate in the first 15 minutes in the ephedrine 0.4mg per kg body weight and 0.25 mg per kg body weight group was statistically significant higher than those of ephedrine 0.1 mg per kg body weight and control group [P<0.001]. The incidence of tachycardia was more in ephedrine 0.4 mg per kg body weight and 0.25 mg per kg body weight groups as compared to ephedrine 0.1 mg per kg body weight and the control group, 9 [45%], 6 [30%] vs. 3 [15%], 2 [10%] respectively. There were significant decrease in total doses of rescue ephedrine required in the ephedrine 0.4mg per kg body weight group as compared to other three groups. Total doses of used ephedrine in all groups were similar. We conclude that although ephedrine 0.25 mg per kg body weight reduces the hypotension but the smallest effective dose of ephedrine to reduce the incidence of hypotension significantly was 0.4mg per kg body weight

Indicaciones y contraindicaciones anestésicas durante la cesárea de gestantes con toxemia leve o grave / Anesthetic indications and contraindications during cesarean section to pregnant women with mild or severe toxemia

Se realizó una exhaustiva revisión bibliográfica, en la cual se investigaron los aspectos de interés para el equipo de anestesiología en la intervención quirúrgica a gestantes con toxemia leve o grave, pues el conocimiento previo de los antecedentes patológicos personales y factores de riesgo que puedan incidir desfavorablemente sobre el cuadro clínico, ya complejo en extremo, permitirá proceder con mayor seguridad profesional y mejorar el pronóstico de estas grávidas complicadas.

An exhaustive literature review, in which interesting aspects were investigated for the anesthesiology team in the surgical procedure of pregnant women with mild or severe toxemia was carried out, as the previous knowledge of the personal pathological background and the risk factors that can influence unfavorably on the extremely complex clinical picture, will allow to proceed with greater professional security and to improve the prognosis of these women with serious complications.

Venous Air Embolism during Surgery, Especially Cesarean Delivery

Venous air embolism (VAE) is the entrapment of air or medical gases into the venous system causing symptoms and signs of pulmonary vessel obstruction. The incidence of VAE during cesarean delivery ranges from 10 to 97% depending on surgical position or diagnostic tools, with a potential for life-threatening events. We reviewed extensive literatures regarding VAE in detail and herein described VAE during surgery including cesarean delivery from background and history to treatment and prevention. It is intended that present work will improve the understanding of VAE during surgery.

Peripartum Cardiomyopathy: Review of the Literature

Peripartum cardiomyopathy (PPCM) is a rare but serious form of cardiac failure affecting women in the last months of pregnancy or early puerperium. Clinical presentation of PPCM is similar to that of systolic heart failure from any cause, and it can sometimes be complicated by a high incidence of thromboembolism. Prior to the availability of echocardiography, diagnosis was based only on clinical findings. Recently, inclusion of echocardiography has made diagnosis of PPCM easier and more accurate. Its etiopathogenesis is still poorly understood, but recent evidence supports inflammation, viral infection and autoimmunity as the leading causative hypotheses. Prompt recognition with institution of intensive treatment by a multidisciplinary team is a prerequisite for improved outcome. Conventional treatment consists of diuretics, beta blockers, vasodilators, and sometimes digoxin and anticoagulants, usually in combination. In resistant cases, newer therapeutic modalities such as immunomodulation, immunoglobulin and immunosuppression may be considered. Cardiac transplantation may be necessary in patients not responding to conventional and newer therapeutic strategies. The role of the anesthesiologist is important in perioperative and intensive care management. Prognosis is highly related to reversal of ventricular dysfunction. Compared to historically higher mortality rates, recent reports describe better outcome, probably because of advances in medical care. Based on current information, future pregnancy is usually not recommended in patients who fail to recover heart function. This article aims to provide a comprehensive updated review of PPCM covering etiopathogeneses, clinical presentation and diagnosis, as well as pharmacological, perioperative and intensive care management and prognosis, while stressing areas that require further research.

Anaesthesia-related maternal mortality.

Complications of anaesthesia leading to death in young pregnant women might be prevented if more experienced personnel could be entrusted with the job. The contribution of anaesthesia to maternal mortality in the United Kingdom is 1.7 per million pregnancies with almost similar incidence from United States. The commonest single factor responsible for anaesthesia-related death is difficult or failed intubation. A pregnant woman with a potentially difficult airway should receive aspiration prophylaxis (mechanical or pharmacological) as soon as operative delivery is anticipated. Anaesthetists should make a plan that comes into effect as soon as failure to view the larynx or to intubate the trachea becomes evident. Unsuspected difficult airway can be managed if the skill of the anaesthetists is of high standard. Pulmonary aspiration is one cause of death in obstetric anaesthesia. Regurgitation and vomiting prevention can minimise pulmonary aspiration. In regional anaesthesia, local anaesthetics toxicity is another cause of concern. This should be tackled with some safe local anaesthetics. Preventing a high spinal or epidural block involves ways to detect inadvertent injection of local anaesthetic into the cerebrospinal fluid. Postoperative care after anaesthesia in obstetric cases is very important.

Las lecciones derivadas del ASA Closed Claims Project (ASACCP). Proyecto de la ASA acerca de las razones que promovieron demandas contra anestesiólogos cuyos casos estaban ya archivados (2a parte): La paciente obstétrica. Una actualización / Lessons learned from the ASA Closed Claims Project (ASACCP). ASA Project about the reasons for wich claims against anesthesiologists were rewed in cases that had already been close (part 2): The obstetric patient. An update

El análisis de los últimos casos relacionados con el tema fue publicado en el año 1996 cuando en la base de la ASACCP constaban 3533 demandas terminadas. De éstas, 434 estuvieron relacionadas con la anestesia obstétrica. De las 434 demandas relacionadas con la anestesia obstétrica, 310 correspondieron a la operación cesárea y 124 al parto por vía vaginal con anestesia regional. Las muertes maternas (n=83) y el daño cerebral del recién nacido (n=82) continúan siendo las injurias más frecuentes en las pacientes obtétricas. La muerte materna estuvo más comúnmente relacionada con la anestesia general y con la operación cesárea. A pesar de que el número de muertes maternas consecutivas a la anestesia general se mantuvo estable a través de los años, el número de muertes asociadas a la anestesia regional declinó en forma marcada. Este decremento de muertes maternas bajo anestesia regional ocurrió sobre todo en los años 80, coincidiendo con la prohibición del uso de bupivacaína al 0,75 por ciento. Además, esta declinación se debe, sin duda, a la solución de los problemas creados por la vía aérea, la cual es más difícil de acceder en la mujer embarazada (1:270 en la paciente obstétrica, contra 1:2.230 de la no obstétrica). La necesidad de controlar la vía aérea es crucial para reducir los casos de muerte durante anestesia general. Lo mismo sucede con la anestesia regional cuando la altura del bloqueo es muy elevada o por cualquier otra razón que obligue a convertir una anestesia regional en una general. Siempre existe el temido problema de la aspiración de contenido gástrico, que sigue siendo la primera causa de muerte materna durante la anestesia y casi siempre asociada con una intubación dificultosa o fallida. El daño cerebral del recién nacido se produjo en el 19 por ciento de las demandas estudiadas por la ASACCP. En una Unidad de Cuidados Intensivo de recién nacidos en EE.UU se realizó un estudio retrospectivo, como los estudios de la ASACCP, para analizar el número de demandas relacionadas con los casos internados en dicha unidad. El estudio comprendió el período 1972-1992 durante el cual se produjeron 31 demandas por mala praxis sobre 9367 internaciones, con una incidencia de 0,33 por ciento. Según los autores, la frecuencia de juicios contra los anestesiólogos por problemas vinculados con el recién nacido se incrementó del 0,19 por ciento entre los años 1772-1974 al 0,39 entre 1980 y 1992...