Do you mind the role of spinal sensory block duration in a crucial endocrine disorder of diabetes mellitus? A prospective observational study.

OBJECTIVE: Diabetes mellitus, per se, is a global health concern, which is often accompanied by complications such as diabetic neuropathy. This prospective observational study purposed to assess the durations of spinal sensory block and motor blocks in individuals with and without diabetes mellitus who had undergone spinal anesthesia. METHODS: This study incorporated 80 cases, which were evenly divided into spinal sensory block without diabetes mellitus and spinal sensory block with diabetes mellitus. Various parameters were recorded at different time points, including heart rate, mean arterial blood pressure, SpO2, and spinal block characteristics. Notable measures included maximum spinal sensory block onset time, time to reach the 10th thoracic vertebra (T10), maximal spinal sensory block, time for Bromage scores, and block regression while controlling for age-related variations. RESULTS: Patients in the diabetic group exhibited extended block durations, with significant differences in heart rate noted at specific time points. Regarding the spinal block characteristics, the "maximum onset of SSB" and the "time to reach the T10" were more prolonged in the SSBwDM without significance. Maximum sensory spinal sensory block did not differ. However, some cases in the SSBwDM displayed blocks extending up to the T6. The times to achieve Bromage motor block scores 1-3 were shorter in SSBwDM and lost significance regarding age. Notably, the regression time was longer in SSBwDM, which held significance for both parameters. CONCLUSION: Diabetic cases commonly encounter prolonged block durations post-subarachnoid intervention, potentially linked to nerve sensitivity, age-related changes, and glycemic control. As such, attenuated local doses for diabetic neuropathic cases may enhance early mobilization, attenuate thromboembolic events, and expedite gastrointestinal recovery.

Safety and effectiveness of adding fentanyl or sufentanil to spinal anesthesia: systematic review and meta-analysis of randomized controlled trials

Abstract Introduction Spinal infusions of either fentanyl or sufentanil have been reported in international reports, articles, and scientific events worldwide. This study aimed to determine whether intrathecal fentanyl or sufentanil offers safety in mortality and perioperative adverse events. Methods MEDLINE (via PubMed), EMBASE, CENTRAL (Cochrane library databases), gray literature, hand-searching, and clinicaltrials.gov were systematically searched. Randomized controlled trials with no language, data, or status restrictions were included, comparing the effectiveness and safety of adding spinal lipophilic opioid to local anesthetics (LAs). Data were pooled using the random-effects models or fixed-effect models based on heterogeneity. Results The initial search retrieved 4469 records; 3241 records were eligible, and 3152 articles were excluded after reading titles and abstracts, with a high agreement rate (98.6%). After reading the full texts, 76 articles remained. Spinal fentanyl and sufentanil significantly reduced postoperative pain and opioid consumption, increased analgesia and pruritus. Fentanyl, but not sufentanil, significantly reduced both postoperative nausea and vomiting, and postoperative shivering; compared to LAs alone. The analyzed studies did not report any case of in-hospital mortality related to spinal lipophilic opioids. The rate of respiratory depression was 0.7% and 0.8% when spinal fentanyl or sufentanil was added and when it was not, respectively. Episodes of respiratory depression were rare, uneventful, occurred intraoperatively, and were easily manageable. Conclusion There is moderate to high quality certainty that there is evidence regarding the safety and effectiveness of adding lipophilic opioids to LAs in spinal anesthesia.

Incidence of bradycardia during noradrenaline or phenylephrine bolus treatment of postspinal hypotension in cesarean delivery: A randomized double-blinded controlled trial.

The treatment of choice for spinal anesthesia-induced hypotension during cesarean section is phenylephrine. As this vasopressor can cause reflex bradycardia, noradrenaline is a suggested alternative. This randomized double-blinded controlled trial included 76 parturients undergoing elective cesarean delivery under spinal anesthesia. Women received noradrenaline in bolus doses of 5 mcg or phenylephrine in bolus doses of 100 mcg. These drugs were used intermittently and therapeutically to maintain systolic blood pressure ≥ 90% of its baseline value. The primary study outcome was bradycardia incidence (<60 bpm) with intermittent bolus administration of these drugs. Secondary outcomes included extreme bradycardia (<40 bpm), number of bradycardia episodes, hypertension (systolic blood pressure > 120% of baseline value), and hypotension (systolic blood pressure < 90% of baseline value and requiring vasopressor use). Neonatal outcomes per the Apgar scale and umbilical cord blood gas analysis were also compared. The incidence of bradycardia in both groups (51.4% and 70.3%, respectively; p = 0.16) were not significantly different. No neonates had umbilical vein or artery pH values below 7.20. The noradrenaline group required more boluses than phenylephrine group (8 vs. 5; p = 0.01). There was no significant intergroup difference in any of the other secondary outcomes. When administered in intermittent bolus doses for the treatment of postspinal hypotension in elective cesarean delivery, noradrenaline, and phenylephrine have a similar incidence of bradycardia. When treating hypotension related to spinal anesthesia in obstetric cases, strong vasopressors are commonly administered, thought these can also have side effects. This trial assessed bradycardia after bolus administration of noradrenaline or phenylephrine, and found no difference in risk for clinically meaningful bradycardia.

Preoperative assessment of inferior vena cava collapsibility index by ultrasound is not a reliable predictor of post-spinal anesthesia hypotension.

BACKGROUND: Post-spinal anesthesia hypotension is of common occurrence, and it hampers tissue perfusion. Several preoperative factors determine patient susceptibility to hypotension. This study aimed to assess the effectiveness of the Inferior Vena Cava Collapsibility Index (IVCCI) for predicting intraoperative hypotension. METHODS: One hundred twenty-nine adult patients who were scheduled for elective surgical procedures after administration of spinal (intrathecal) anesthesia were included in the study. Ultrasound evaluation of the Inferior Vena Cava (IVC) was done in the preoperative area, and the patients were shifted to the Operating Room (OR) for spinal anesthesia. An independent observer recorded the change in blood pressure after spinal anesthesia inside the OR. RESULTS: Twenty-five patients developed hypotension (19.37%). Baseline systolic blood pressure and mean blood pressures were statistically higher in those patients who developed hypotension (p = 0.001). The logistic regression analysis for IVCCI and the incidence of hypotension showed r2 of 0.025. Receiver Operating Characteristic (ROC) curve analysis demonstrated the Area Under the Curve (AUC) of 0.467 (95% Confidence Interval, 0.338 to 0.597; p = 0.615). CONCLUSIONS: Preoperative evaluation of IVCCI is not a good predictor for the occurrence of hypotension after spinal anesthesia.

Safety and effectiveness of adding fentanyl or sufentanil to spinal anesthesia: systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Spinal infusions of either fentanyl or sufentanil have been reported in international reports, articles, and scientific events worldwide. This study aimed to determine whether intrathecal fentanyl or sufentanil offers safety in mortality and perioperative adverse events. METHODS: MEDLINE (via PubMed), EMBASE, CENTRAL (Cochrane library databases), gray literature, hand-searching, and clinicaltrials.gov were systematically searched. Randomized controlled trials with no language, data, or status restrictions were included, comparing the effectiveness and safety of adding spinal lipophilic opioid to local anesthetics (LAs). Data were pooled using the random-effects models or fixed-effect models based on heterogeneity. RESULTS: The initial search retrieved 4469 records; 3241 records were eligible, and 3152 articles were excluded after reading titles and abstracts, with a high agreement rate (98.6%). After reading the full texts, 76 articles remained. Spinal fentanyl and sufentanil significantly reduced postoperative pain and opioid consumption, increased analgesia and pruritus. Fentanyl, but not sufentanil, significantly reduced both postoperative nausea and vomiting, and postoperative shivering; compared to LAs alone. The analyzed studies did not report any case of in-hospital mortality related to spinal lipophilic opioids. The rate of respiratory depression was 0.7% and 0.8% when spinal fentanyl or sufentanil was added and when it was not, respectively. Episodes of respiratory depression were rare, uneventful, occurred intraoperatively, and were easily manageable. CONCLUSION: There is moderate to high quality certainty that there is evidence regarding the safety and effectiveness of adding lipophilic opioids to LAs in spinal anesthesia.

Preoperative assessment of inferior vena cava collapsibility index by ultrasound is not a reliable predictor of post-spinal anesthesia hypotension

Abstract Background Post-spinal anesthesia hypotension is of common occurrence, and it hampers tissue perfusion. Several preoperative factors determine patient susceptibility to hypotension. This study aimed to assess the effectiveness of the Inferior Vena Cava Collapsibility Index (IVCCI) for predicting intraoperative hypotension. Methods One hundred twenty-nine adult patients who were scheduled for elective surgical procedures after administration of spinal (intrathecal) anesthesia were included in the study. Ultrasound evaluation of the Inferior Vena Cava (IVC) was done in the preoperative area, and the patients were shifted to the Operating Room (OR) for spinal anesthesia. An independent observer recorded the change in blood pressure after spinal anesthesia inside the OR. Results Twenty-five patients developed hypotension (19.37%). Baseline systolic blood pressure and mean blood pressures were statistically higher in those patients who developed hypotension (p= 0.001). The logistic regression analysis for IVCCI and the incidence of hypotension showed r2 of 0.025. Receiver Operating Characteristic (ROC) curve analysis demonstrated the Area Under the Curve (AUC) of 0.467 (95% Confidence Interval, 0.338 to 0.597; p= 0.615). Conclusions Preoperative evaluation of IVCCI is not a good predictor for the occurrence of hypotension after spinal anesthesia.

Intracranial rebleeding post spinal anesthesia in pregnant patient with undiagnosed chronic subdural hematoma: case report.

Intracranial hematoma after spinal anesthesia is a rare complication. It generally presents with posture-dependent headache that becomes persistent. We describe the case of patient submitted to spinal anesthesia for cesarean section who presented a non-posture-dependent headache, resistant to clinical treatment, that progressively worsened and with symptoms of intracranial hypertension. The patient had a history of head trauma without symptoms. The CT-scan revealed a chronic bilateral parietal hematoma with a recent bleeding component, treated surgically. We concluded that spinal puncture led to chronic hematoma to rebleed. We have reported the case to draw attention to the importance of investigating atypical headache after spinal anesthesia.

Associated factors with umbilical arterial pH after cesarean delivery under spinal anesthesia: a retrospective cohort study.

BACKGROUND: Maximum decrease of blood pressure and number of minutes of hypotension were independently associated with umbilical arterial pH. However, the impact of hypotension considering the duration of it on umbilical arterial pH is unknown. METHODS: Pregnant women aged ≥ 20 years who delivered a baby at full-term via a cesarean delivery under a single-shot spinal anesthesia between January 2017 and March 2019 were included. The main outcome was to predict umbilical arterial pH, based on the value of the time integral of hypotension. Patient demographics, patient comorbidities, and intraoperative data, including the total dose of ephedrine and phenylephrine by fetal delivery and cumulative duration of maternal hypotension, were evaluated. Maternal hypotension was reflected as a decrease in systolic arterial pressure and mean arterial pressure to < 80% of baseline values. The systolic arterial pressure and mean arterial pressure were independently included in a multiple regression analysis along with all other explanatory factors to predict the umbilical arterial pH. RESULTS: Of the 416 eligible patients, 381 were enrolled. When including the systolic arterial pressure or mean arterial pressure in the model, emergency cases, the total dose of ephedrine, hypertensive disorders of pregnancy, and systolic arterial pressure or mean arterial pressure values were found to be significant predictive factors of umbilical arterial pH. CONCLUSION: Our results suggest that an elevated time integral of maternal hypotension may have a negative impact on umbilical arterial pH. Therefore, to minimize the risk of fetal acidosis, maternal hypotension should be prevented with the consideration of vasopressors selection.

Downregulation of CSF-derived miRNAs miR-142-3p and miR-17-5p may be associated with post-dural puncture headache in pregnant women upon spinal anesthesia.

BACKGROUND: Postdural puncture headache (PDPH) develops due to puncture of the dura mater. The risk factors that influence PDPH incidence are Body Mass Index (BMI), sex, spinal needle type, history of headache, and loss of Cerebrospinal fluid (CSF) volume, yet there is no consensus on these risk factors. The pathophysiology of PDPH is poorly understood. The molecular pathways that may lead to PDPH are unknown. In this study, CSF - derived microRNAs (miRNAs) were investigated for their potential to predispose to PDPH in a population of pregnant women. METHODS: Pregnant women going under cesarean section via spinal anesthesia were included in the study with the criteria of the subjects presenting American Society of Anesthesiologists (ASA) physical status I. Patients were classified into two groups as with PDPH (n = 10) and without PDPH (n = 12) based on International Headache Society's PDPH definition. CSF-derived microRNAs were investigated for their differential expression levels in PDPH patients compared with the healthy controls using microfluidic gene expression platform. RESULTS: Out of seventy-six miRNAs, two miRNAs, namely miR-142-3p and miR-17-5p, were significantly downregulated in PDPH patients (Mann-Whitney U test, p < 0,05). BMI and age did not influence PDPH occurrence. The mean visual analogue scale (VAS) of the PDPH patients was 6,8 out of 10. CONCLUSION: We have shown that downregulation of miR-142-3p and miR-17-5p may predispose pregnant women to PDPH upon spinal anesthesia. However, which genes are targeted by miR-142-3p and miR-17-5p-mediated effect on PDPH remains to be elucidated.

Mielitis transversa aguda asociada a anestesia espinal: Caso clínico / Acute transverse myelitis related to spinal anesthesia: Case report

Neurological impairment after neuraxial anesthesia is very uncommon, but with possible severe consequences. We report the case of a 30-year-old patient scheduled for elective surgery under spinal anesthesia who presented pain during the procedure and neurological impairment in the lower extremities during the postoperative period. The specialized analysis of the case and the paitient's evolution showed that the cause was an acute transverse myelitis. The relationship between this entity and anesthesia is controversial; however, it must be considered in patients undergoing neuroaxial anesthesia who evolve with postoperative neurological impairment and pain in their lower extremities, even though there are no warning symptoms during the procedure. The objective of this report is to alert about the importance of the observation in patients who present pain during neuraxial anesthesia and the prompt evaluation of those who evolve with pain or neurological impairment after the procedure.

El déficit neurológico después de anestesia neuroaxial es de ocurrencia muy infrecuente, pero de posibles consecuencias severas. Reportamos el caso de un paciente de 30 años programado para cirugía electiva bajo anestesia espinal que presentó dolor durante el procedimiento y déficit neurológico de extremidades inferiores en el posoperatorio inmediato. El análisis especializado del caso y su evolución clínica mostraron que se trataba de una mielitis transversa aguda. La relación entre esta entidad y anestesia es controversial; sin embargo, debe ser considerada en los diagnósticos diferenciales en pacientes sometidos a anestesia neuroaxial que evolucionen con dolor y déficit neurológico posoperatorio en sus extremidades inferiores, a pesar de que no haya síntomas de alerta durante el procedimiento. El objetivo de este reporte es alertar acerca de la importancia de la observación de pacientes que presenten dolor durante la anestesia neuroaxial y el estudio inmediato de aquellos que evolucionen con dolor o déficit neurológico después del procedimiento.

Medicina perioperatoria para operación cesárea / Perioperative medicine in cesarian section

INTRODUCTION: Caesarean section is the most frequent surgery worldwide, the ideal rate for this procedure should be 19%, currently it's on the rise worldwide. To reduce the morbidity and mortality associated with anesthetic-surgical procedures in pregnant patients, correct perioperative assessment is necessary, capable of recognizing the risks to which these patients are exposed and being able to create strategies to reduce them. OBJECTIVE: The patients present risks inherent of pregnancy condition. The following work is carried out with the aim of prioritizing the preoperative assessment for the patient undergoing cesarean delivery to reduce maternal-fetal morbidity and mortality associated with anesthetic-surgical procedures. METHODOLOGY: A non-systematized bibliographic search was carried out in Pubmed, Medline, Portal Timbo, Scielo databases to evaluate the perioperative management of cesarean section. The reference keywords used were "cesarean section", "anesthesia", "perioperative care", "maternal mortality". RESULTS: A review of the perioperative management for cesarean section was carried out, emphasizing the recognition of risks to which the patients are exposed and strategies to reduce them are proposed with the aim of reducing the morbidity and mortality of the patients. CONCLUSIONS: Patients undergoing cesarean delivery have a high risk of complications, the most common are presented in the manipulation of the airway, aspiration of gastric content, infections, bleeding, and thrombosis, recognizing these risks and acting on each one of them can reduce the morbidity and mortality of patients.

INTRODUCCIÓN: La cesárea es la cirugía más frecuente a nivel mundial, actualmente la misma viene en ascenso. Para disminuir la morbimortalidad asociada a los procedimientos anestésico-quirúrgicos en la paciente embarazada es necesario una correcta valoración perioperatoria capaz de reconocer los riesgos a los cuales estas pacientes están expuestas y poder crear estrategias para disminuir los mismos. OBJETIVO: Las pacientes presentan riesgos inherentes a su condición de gravidez. Se realiza el siguiente trabajo con el objetivo de priorizar la valoración preoperatoria para la paciente sometida a parto por cesárea con la finalidad de disminuir la morbimortalidad materno-fetal asociada a procedimientos anestésicoquirúrgicos. METODOLOGÍA: Se realizó una búsqueda bibliográfica no sistematizada en bases de datos Pubmed, Medline, Portal Timbo, Scielo, para evaluar el manejo perioperatorio de la cesárea. Se utilizaron como palabras clave de referencia "cesarean section", "anesthesia", "perioperative care", "maternal mortality". RESULTADOS: Se realizó una revisión del manejo perioperatorio para la cesárea, se realiza énfasis en el reconocimiento de riesgos a los cuales las pacientes están expuestas y se plantean estrategias de disminución de estos con el objetivo de reducir la morbimortalidad de las pacientes. CONCLUSIONES: Las pacientes sometidas a parto por cesárea presentan alto riesgo de complicaciones, las más comunes se presentan en la manipulación de la vía aérea, aspiración de contenido gástrico, infecciones, sangrado y trombosis, reconociendo dichos riesgos y actuando sobre cada uno de ellos se puede disminuir la morbimortalidad de las pacientes.

Spinal anesthesia for elective cesarean section. Bupivacaine associated with different doses of fentanyl: randomized clinical trial.

OBJECTIVE: Assess patients submitted to elective cesarean section under spinal anesthesia, and the efficacy of different doses of fentanyl associated with bupivacaine. METHODS: The study included 124 pregnant women randomly distributed into 4 groups (n = 31) according to different doses of fentanyl (15 µg, 10 µg, 7.5 µg), Groups I, II, and III, respectively, and control group IV, associated with 0.5% hyperbaric bupivacaine (10 mg). An epidural catheter was inserted in case epidural top-up was required. We assessed the anesthetic blockage characteristics, negative maternal and neonatal outcomes, and maternal side effects. Statistical analysis was performed using Kruskal-Wallis, Fisher's exact and chi-square tests. The level of significance was 5% (p < 0.05). RESULTS: The quality of analgesia, time for the first complaint of pain and motor block recovery time were significantly better for groups that received fentanyl in comparison to controls (p < 0.001). None of the groups had negative maternal-fetal outcomes. Nausea was significantly more frequent in patients in Groups II (10 µg) and III (7.5 µg) when compared to Groups I (15 µg) and IV (no fentanyl). Vomiting was more frequent in Group III than in Group I (p = 0.006). The incidence of pruritus was significantly higher in the groups receiving fentanyl (p = 0.012). CONCLUSIONS: Among the solutions studied, the spinal anesthesia technique using 15 µg of fentanyl associated with 10 mg of hyperbaric bupivacaine provided satisfactory analgesia and very low incidence of adverse effects for patients submitted to cesarean section. TRIAL REGISTRATION NUMBER: UTN U1111-1199-0285. REBEC: RBR-5XWT6T.

Effect of ondansetron on spinal anesthesia-induced hypotension in non-obstetric surgeries: a randomised, double-blind and placebo-controlled trial.

BACKGROUND AND OBJECTIVES: Spinal anesthesia is an effective technique for many surgical procedures, but it is often associated with an increased risk of potentially deleterious hemodynamic disturbances. The benefits of prophylactic ondansetron for preventing spinal anesthesia-induced hypotension are still uncertain. Therefore, this study aimed to compare the effect of ondansetron and placebo before spinal block on the incidence of hypotension in patients having non-obstetric surgeries. METHODS: Randomized, double-blind, parallel-group, superiority trial with a 1:1 allocation ratio. A total of 144 patients scheduled for non-obstetric surgeries with an indication for spinal anesthesia were randomized. Patients received intravenous ondansetron (8mg) or placebo before standard spinal anesthesia. The primary outcome was the rate of hypotension in the first 30 minutes after spinal anesthesia. RESULTS: Hypotension occurred in 20 of 72 patients (27.8%) in the ondansetron group and in 36 of 72 patients (50%) in the placebo group (Odds Ratio-OR=0.38; 95% Confidence Interval-CI 0.19 to 0.77; p=0.007). Fewer patients in the ondansetron group required ephedrine compared to the placebo group (13.9% vs. 27.8%; OR=0.42; 95% CI 0.18 to 0.98; p=0.04). Exploratory analyses revealed that ondansetron may be more effective than placebo in patients aged 60 years or older (OR=0.12; 95% CI 0.03 to 0.48; p=0.03). No difference in heart rate variations was observed. CONCLUSION: Our findings suggest that ondansetron can be a viable and effective strategy to reduce both the incidence of spinal anesthesia-induced hypotension and vasopressors usage in non-obstetric surgeries.

The effect of epinephrine for the treatment of spinal-hypotension: comparison with norepinephrine and phenylephrine, clinical trial / O efeito de epinefrina, norepinefrina e fenilefrina no tratamento da hipotensão pós-raquianestesia: estudo clínico comparativo

Abstract Background and objectives: Limited data are present on safety and efficiency of epinephrine for the prophylaxis and treatment of spinal-hypotension. This study was conducted to compare the effect of epinephrine with norepinephrine and phenylephrine on the treatment of spinal-hypotension and ephedrine requirement during cesarean delivery. Methods: One hundred and sixty parturients with uncomplicated pregnancies undergoing elective cesarean delivery under spinal anesthesia were recruited. They were allocated randomly to receive norepinephrine 5 µg.mL−1 (n = 40), epinephrine 5 µg.mL−1 (n = 40), phenylephrine 100 µg.mL−1 (n = 40) or 0.9% saline infusions (n = 40) immediately after induction of spinal anesthesia. Whenever systolic blood pressure drops to less than 80% of baseline, 5 mg of intravenous ephedrine was administered as rescue vasopressor. The incidence of hypotension, total number of hypotension episodes, the number of patients requiring ephedrine, the mean amount of ephedrine consumption and side effects were recorded. Results: There was no statistically significant difference in incidence of maternal hypotension between groups. The number of patients requiring ephedrine was significantly greater in group saline than in group phenylephrine (p< 0.001). However, it was similar between phenylephrine, norepinephrine, and epinephrine groups. The mean ephedrine consumption was significantly higher in group saline than in norepinephrine, epinephrine, phenylephrine groups (p= 0.001). Conclusion: There is no statistically significant difference in incidence of hypotension and ephedrine consumption during spinal anesthesia for cesarean delivery with the use of epinephrine when compared to norepinephrine or phenylephrine. Epinephrine can be considered an alternative agent for management of spinal hypotension.

Resumo Justificativa e objetivos: Existem dados limitados sobre segurança e eficiência da epinefrina na profilaxia e tratamento da hipotensão arterial associada à raquianestesia. O presente estudo foi realizado para comparar o efeito da epinefrina com norepinefrina e fenilefrina no tratamento da hipotensão após raquianestesia e necessidade de efedrina durante o parto cesáreo. Método: Foram recrutadas 160 parturientes com gestações não complicadas, submetidas a cesariana eletiva sob raquianestesia. Elas foram alocadas aleatoriamente para receber norepinefrina 5 µg.mL-1 (n = 40), epinefrina 5 µg.mL-1 (n = 40), fenilefrina 100 µg.mL-1 (n = 40) ou infusão de solução fisiológica NaCl a 0,9% (n = 40) imediatamente após a indução da raquianestesia. Sempre que houvesse redução da pressão arterial sistólica para valor inferior a 80% da linha de base, 5 mg de efedrina iv eram administrados como vasopressor de resgate. A incidência de hipotensão, o número total de episódios de hipotensão, o número de pacientes que necessitaram de efedrina, o consumo médio de efedrina e os efeitos colaterais foram registrados. Resultados: Não houve diferença estatisticamente significante na incidência de hipotensão materna entre os grupos. O número de pacientes que necessitaram de efedrina foi significantemente maior no grupo solução fisiológica do que no grupo fenilefrina (p< 0,001). No entanto, foi semelhante entre os grupos fenilefrina, norepinefrina e epinefrina. O consumo médio de efedrina foi significantemente maior no grupo solução fisiológica do que nos grupos norepinefrina, epinefrina e fenilefrina (p = 0,001). Conclusão: Não houve diferença estatisticamente significante na incidência de hipotensão e consumo de efedrina durante raquianestesia para parto cesáreo com uso de epinefrina quando comparada à norepinefrina ou fenilefrina. A epinefrina pode ser considerada como agente alternativo para o tratamento da hipotensão após raquianestesia.

Risk factors for post-caesarean nausea and vomiting: a prospective prognostic study / Fatores de risco para náusea e vômitos após cesariana: estudo prognóstico prospectivo

Abstract Background: Postoperative Nausea and Vomiting (PONV) risk factors have not been defined for obstetric patients. In this study, our objective was to identify potential risk factors for PONV after cesarean sections performed under spinal anesthesia. Methods: One cohort of patients submitted to cesarean under spinal anesthesia was used to investigate potential risk factors for PONV. The best numerical risk factors were dichotomized using chi-squared method. A conditional independence (incremental association method) casual network was used to select the best predictors for PONV. Results: Two hundred and fifty of 260 patients remained in the study. Odds ratio for PONV of younger maternal age (< 25 years: 2.9 [1.49−5.96]), lower spinal bupivacaine dose (< 13 mg, inf [2.4-inf]), lower spinal morphine dose (< 80 mg, 0.03 [0−0.97]), history of motion sickness (2.5 [1.27−5.25]), significant nausea during the first trimester (0.3 [0.16−0.64]), intraoperative nausea and vomiting (8.2 [3.67−20.47]), and lower gestational age (< 38 weeks, 2.0 [1.01−4.08]) were statistically significant. The causal network selected absence of significant nausea during the first gestational trimester, intraoperative nausea, and gestational age < 38 weeks as the main direct risk factors for PONV. Conclusions: Intraoperative nausea and maternal age < 25 years were the main risk factors for PONV after cesareans under spinal anesthesia. Absence of self-reported nausea during the first trimester was a protective factor for post-cesarean nausea and vomiting.

Resumo Introdução: Os fatores de risco para náusea e vômitos pós-operatórios (NVPO) ainda não foram definidos para pacientes de obstetrícia. Neste estudo, nosso objetivo foi identificar potenciais fatores de risco para NVPO após parto cesariano realizado sob raquianestesia. Método: Uma coorte de pacientes submetidas a cesariana sob raquianestesia foi usada para investigar potenciais fatores de risco para NVPO. Os melhores fatores de risco numéricos foram dicotomizados por meio do método qui-quadrado. Uma rede casual de independência condicional (método de associação adicional) foi usada para selecionar os melhores preditores de NVPO. Resultados: Das 260 pacientes iniciais, 250 completaram o estudo. A razão de chances para NVPO foi estatisticamente significante para menor idade materna (< 25 anos: 2,9 [1,49−5,96]), dose mais baixa de bupivacaina raquidiana (< 13 mg, inf [2,4-inf]), dose mais baixa de morfina raquidiana (< 80 mg, 0,03 [0−0,97]), histórico de enjoo de movimento (2,5 [1,27−5,25]), náuseas importantes durante o primeiro trimestre (0,3 [0,16−0,64]), náusea e vômitos intraoperatórios (8,2 [3,67−20,47]) e menor idade gestacional (< 38 semanas, 2,0 [1,01−4,08]). A rede causal selecionou ausência de náuseas significativas durante o primeiro trimestre gestacional, náusea intraoperatória e idade gestacional < 38 semanas como os principais fatores de risco diretos para NVPO. Conclusões: Náusea intraoperatória e idade materna < 25 anos foram os principais fatores de risco para NVPO após cesariana sob raquianestesia. A ausência de náusea autorreferida durante o primeiro trimestre foi um fator protetor para náusea e vômitos após cesariana.

[Risk factors for post-caesarean nausea and vomiting: a prospective prognostic study]. / Fatores de risco para náusea e vômitos após cesariana: estudo prognóstico prospectivo.

BACKGROUND: Postoperative Nausea and Vomiting (PONV) risk factors have not been defined for obstetric patients. In this study, our objective was to identify potential risk factors for PONV after cesarean sections performed under spinal anesthesia. METHODS: One cohort of patients submitted to cesarean under spinal anesthesia was used to investigate potential risk factors for PONV. The best numerical risk factors were dichotomized using chi-squared method. A conditional independence (incremental association method) casual network was used to select the best predictors for PONV. RESULTS: Two hundred and fifty of 260 patients remained in the study. Odds ratio for PONV of younger maternal age (< 25 years: 2.9 [1.49-5.96]), lower spinal bupivacaine dose (< 13 mg, inf [2.4-inf]), lower spinal morphine dose (< 80 mg, 0.03 [0-0.97]), history of motion sickness (2.5 [1.27-5.25]), significant nausea during the first trimester (0.3 [0.16-0.64]), intraoperative nausea and vomiting (8.2 [3.67-20.47]), and lower gestational age (< 38 weeks, 2.0 [1.01-4.08]) were statistically significant. The causal network selected absence of significant nausea during the first gestational trimester, intraoperative nausea, and gestational age < 38 weeks as the main direct risk factors for PONV. CONCLUSIONS: Intraoperative nausea and maternal age < 25 years were the main risk factors for PONV after cesareans under spinal anesthesia. Absence of self-reported nausea during the first trimester was a protective factor for post-cesarean nausea and vomiting.

[The effect of epinephrine for the treatment of spinal-hypotension: comparison with norepinephrine and phenylephrine, clinical trial]. / O efeito de epinefrina, norepinefrina e fenilefrina no tratamento da hipotensão pós­raquianestesia: estudo clínico comparativo.

BACKGROUND AND OBJECTIVES: Limited data are present on safety and efficiency of epinephrine for the prophylaxis and treatment of spinal-hypotension. This study was conducted to compare the effect of epinephrine with norepinephrine and phenylephrine on the treatment of spinal-hypotension and ephedrine requirement during cesarean delivery. METHODS: One hundred and sixty parturients with uncomplicated pregnancies undergoing elective cesarean delivery under spinal anesthesia were recruited. They were allocated randomly to receive norepinephrine 5 µg.mL-1 (n=40), epinephrine 5 µg.mL-1 (n=40), phenylephrine 100 µg.mL-1 (n=40) or 0.9% saline infusions (n=40) immediately after induction of spinal anesthesia. Whenever systolic blood pressure drops to less than 80% of baseline, 5 mg of iv ephedrine was administered as rescue vasopressor. The incidence of hypotension, total number of hypotension episodes, the number of patients requiring ephedrine, the mean amount of ephedrine consumption and side effects were recorded. RESULTS: There was no statistically significant difference in incidence of maternal hypotension between groups. The number of patients requiring ephedrine was significantly greater in group saline than in group phenylephrine (p <0.001). However, it was similar between phenylephrine, norepinephrine, and epinephrine groups. The mean ephedrine consumption was significantly higher in group saline than in norepinephrine, epinephrine, phenylephrine groups (p=0.001). CONCLUSION: There is no statistically significant difference in incidence of hypotension and ephedrine consumption during spinal anesthesia for cesarean delivery with the use of epinephrine when compared to norepinephrine or phenylephrine. Epinephrine can be considered as an alternative agent for management of spinal hypotension.