Maternal hemodynamics and computerized cardiotocography during labor with epidural analgesia.

PURPOSE: To analyze the mechanisms involved in the fetal heart rate (FHR) abnormalities after the epidural analgesia in labor. METHODS: A prospective unblinded single-center observational study on 55 term singleton pregnant women with spontaneous labor. All women recruited underwent serial bedside measurements of the main hemodynamic parameters using a non-invasive ultrasound system (USCOM-1A). Total vascular resistances (TVR), heart rate (HR), stroke volume (SV), cardiac output (CO) and arterial blood pressure were measured before epidural administration (T0), after 5 min 5 (T1) from epidural bolus and at the end of the first stage of labor (T2). FHR was continuously recorded through computerized cardiotocography before and after the procedure. RESULTS: The starting CO was significantly higher in a subgroup of women with low TVR than in women with high-TVR group. After the bolus of epidural analgesia in the low-TVR group there was a significant reduction in CO and then increased again at the end of the first stage, in the high-TVR group the CO increased insignificantly after the anesthesia bolus, while it increased significantly in the remaining part of the first stage of labor. On the other hand, CO was inversely correlated with the number of decelerations detected on cCTG in the 1 hour after the epidural bolus while the short-term variation was significantly lower in the group with high-TVR. CONCLUSION: Maternal hemodynamic status at the onset of labor can make a difference in fetal response to the administration of epidural analgesia.

Estimated oxygen extraction versus dynamic parameters of fluid-responsiveness for perioperative hemodynamic optimization of patients undergoing non-cardiac surgery: a non-inferiority randomized controlled trial.

BACKGROUND: Goal directed therapy (GDT) is able to improve mortality and reduce complications in selected high-risk patients undergoing major surgery. The aim of this study is to compare two different strategies of perioperative hemodynamic optimization: one based on optimization of preload using dynamic parameters of fluid-responsiveness and the other one based on estimated oxygen extraction rate (O2ER) as target of hemodynamic manipulation. METHODS: This is a multicenter randomized controlled trial. Adult patients undergoing elective major open abdominal surgery will be allocated to receive a protocol based on dynamic parameters of fluid-responsiveness or a protocol based on estimated O2ER. The hemodynamic optimization will be continued for 6 h postoperatively. The primary outcome is difference in overall postoperative complications rate between the two protocol groups. Fluids administered, fluid balance, utilization of vasoactive drugs, hospital length of stay and mortality at 28 day will also be assessed. DISCUSSION: As a predefined target of cardiac output (CO) or oxygen delivery (DO2) seems to be not adequate for every patient, a personalized therapy is likely more appropriate. Following this concept, dynamic parameters of fluid-responsiveness allow to titrate fluid administration aiming CO increase but avoiding fluid overload. This approach has the advantage of personalized fluid therapy, but it does not consider if CO is adequate or not. A protocol based on O2ER considers this second important aspect. Although positive effects of perioperative GDT have been clearly demonstrated, currently studies comparing different strategies of hemodynamic optimization are lacking. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04053595. Registered on 12/08/2019.

Post intubation tracheal stenosis in children.

Many authors have reported that tracheal stenosis is a complication that can follow tracheal intubation in both adults and children. The symptoms, when they do appear, can be confused with asthma, with subsequent treatment providing only mild and inconsistent relief. We report here the case of an 8 year old girl admitted to our hospital for whooping cough that was not responding to therapy.

Epidural analgesia during labor and incidence of cesarian section: prospective study.

For many years the opportunity of reducing the pain of birth through the administering of drugs (e.g. local anesthetics and opioids) into the epidural space has been known. Numerous studies have been conducted throughout the years to clarify whether the use of the epidural has resulted in a higher incidence of cesarean sections but it appears that this is due more to maternal-fetal factors than it is to the epidural. In this study, we have outlined the experience of the Anesthesia and Intensive Care Unit of an Italian Children's Hospital in which approximately-2500 births take place every year and in which there is an active birth analgesia service which requires the presence of a dedicated anesthetist.