RESUMO
The main causes of maternal mortality are comorbidities, hypertensive pregnancy syndrome, obstetric haemorrhage, and maternal sepsis. For this reason, uterotonics, magnesium sulphate, and antibiotics are essential tools in the management of obstetric patients during labour and in the peripartum period. These drugs are widely used by anaesthesiologists in all departments, and play a crucial role in treatment and patient safety. For the purpose of this narrative review, we performed a detailed search of medical databases and selected studies describing the use of these drugs in patients during pregnancy, delivery and the pospartum period. Uterotonics, above all oxytocin, play an important role in the prevention and treatment of pospartum haemorrhage, and various studies have shown that in obstetric procedures, such as scheduled and emergency caesarean section, they are effective at lower doses than those hitherto accepted. We also discuss the use of carbetocin as an effective alternative that has a therapeutic advantage in certain clinical circumstances. Magnesium sulphate is the gold standard in the prevention and treatment of eclampsia, and also plays a neuroprotective role in preterm infants. We describe the precautions to be taken during magnesium administration. Finally, we discuss the importance of understanding microbiology and the pharmacology of antibiotics in the management of obstetric infection and endometritis, and draw attention to the latest trends in antibiotic regimens in labour and caesarean section.
Assuntos
Antibacterianos , Sulfato de Magnésio , Ocitócicos , Humanos , Sulfato de Magnésio/uso terapêutico , Feminino , Gravidez , Antibacterianos/uso terapêutico , Ocitócicos/uso terapêutico , Período Periparto , Anestesia Obstétrica/métodos , Parto Obstétrico , Endometrite/prevenção & controle , Endometrite/tratamento farmacológico , Cesárea , Ocitocina/análogos & derivadosRESUMO
La pandemia de COVID-19 producida por SARS-CoV-2 actualmente en curso anticipa una gran demanda por ventiladores mecánicos (VM), ya que un porcentaje relevante de los contagiados cae rápidamente en insuficiencia respiratoria y requiere de cuidados intensivos. Anticipándose a ese exceso de demanda y considerando que es muy probable que el número actual de ventiladores mecánicos en las unidades de cuidados intensivos (UCI) sean insuficientes, se ha solicitado a la SACH un informe técnico en relación al uso de las máquinas de anestesia como VM.
Assuntos
Pneumonia Viral/terapia , Pneumonia Viral/epidemiologia , Ventiladores Mecânicos/provisão & distribuição , Infecções por Coronavirus/terapia , Infecções por Coronavirus/epidemiologia , Pandemias , Betacoronavirus , Anestesia/métodos , Chile/epidemiologiaRESUMO
BACKGROUND: Transversus abdominis plane block is increasingly used for post-Caesarean section analgesia. Cases of toxicity and the limited pharmacokinetic information during pregnancy motivated this study. The objective of the study was to characterise and compare the pharmacokinetics of levobupivacaine with epinephrine in tranversus abdominis plane block, in post-Caesarean section patients and healthy volunteers. METHODS: After approval by the Ethics Committee, we collected data from 12 healthy parturients after elective Caesarean section (Study 1) and data from 11 healthy male volunteers from a previous study (Study 2). Transversus abdominus plane block was performed under ultrasound guidance. The following injectates were used: levobupivacaine 0.25%, 20 ml with epinephrine 5 µg ml-1 (Study 1) per side; 20 ml of the same solution (unilateral block) (study 2). The plasma venous concentration of levobupivacaine was measured serially for 90 min. Pharmacokinetic parameters (volume of distribution, clearance, and absorption half-life) were estimated using a non-linear mixed effects model (NONMEM). Simulation in 1000 patients estimated the maximum concentration and the time to reach it after bilateral transversus abdominis plane block. RESULTS: Venous concentrations were below toxic levels (2.62 mg L-1). Levobupivacaine volume of distribution after Caesarean section was higher than in healthy volunteers [172 L (70 kg)-1 (95% confidence interval: 137-207) vs 94.3 L (70 kg)-1 (95% CI: 62-128); P<0.01]. Clearance and absorption half-life were similar. The simulation showed that maximum levobupivacaine concentration is lower and occurs later in postpartum patients (P<0.01). Postoperative analgesia was effective. CONCLUSIONS: Postpartum women reached relatively low plasma concentrations of levobupivacaine after transversus abdominal plane block given a volume of distribution 80% higher than volunteers, which could confer a greater margin of safety. CLINICAL TRIAL REGISTRATION: NCT02852720.
Assuntos
Parede Abdominal , Anestésicos Locais/farmacocinética , Cesárea/métodos , Epinefrina/farmacocinética , Levobupivacaína/farmacocinética , Bloqueio Nervoso , Dor Pós-Operatória/tratamento farmacológico , Vasoconstritores/farmacocinética , Adulto , Analgesia Obstétrica , Analgésicos Opioides/uso terapêutico , Simulação por Computador , Feminino , Meia-Vida , Voluntários Saudáveis , Humanos , Masculino , GravidezRESUMO
OBJECTIVE: Analgesia for labor is a legal obligation in Chile. In our institution we implemented patient controlled analgesia for pain relief during labor. We describe the perception of the several professionals involved in the medical care of patients in labor in terms of effectiveness, usefulness, satisfaction, and safety. MATERIAL AND METHODS: A self-reported questionnaire was given to the professionals involved, and the obstetrical and neonatal outcomes were recorded along with the workload indices. Twenty-five structured questions were presented with a Likert type score to evaluate analgesia quality, workload of professionals involved, adverse effects, patient satisfaction, and healthcare workers satisfaction. Finally, a question was asked about the overall perception. RESULTS: We found that the overall perception of the analgesic technique was (mean) 6.0 (SD) (0.88). A decrease in the anesthesiologist workload was observed, without affecting obstetric outcomes. CONCLUSION: Considering the study design limitations, absence of knowledge of economical impact, and the satisfaction level of patients under standard epidural analgesia, we recommend the patient controlled analgesia technique due to its good obstetric outcomes, general satisfaction and workload decrease.
Assuntos
Analgesia Epidural , Analgesia Obstétrica , Analgesia Controlada pelo Paciente , Dor do Parto/tratamento farmacológico , Manejo da Dor/métodos , Inquéritos e Questionários , Chile , Feminino , Hospitais Universitários , Humanos , GravidezRESUMO
Caesarean section is one of the most common surgical procedures worldwide. Arterial hypotension is the most prevalent adverse effect after spinal anaesthesia. Various methods have been used to prevent or treat hypotension. Since there is no treatment 100% effective by itself, a multimodal management is required to achieve an optimum balance and avoidance of hemodynamic imbalance. Strategies to avoid this side effect are analyzed on the basis of the best evidence available so far, summarized as mechanical factors, anesthetics, fluids and vasopressors. After spinal anaesthesia for caesarean section, the best strategy available for prevention of hypotension appears to be the combination of crystalloids along with an alpha 1 agonist vasopressor.
Assuntos
Anestesia Obstétrica , Raquianestesia , Cesárea , Hipotensão/prevenção & controle , Anestesia Obstétrica/métodos , Raquianestesia/efeitos adversos , Raquianestesia/métodos , Feminino , Hidratação , Humanos , Hipotensão/etiologia , Gravidez , Vasoconstritores/uso terapêuticoRESUMO
We present an update of the latest advances in clinical management and images of the most commonly used neuraxial techniques in epidural, subarachnoid, and combined spinal-epidural anesthesia and analgesia.
Assuntos
Analgesia Epidural/métodos , Anestesia Epidural/métodos , Adulto , Humanos , Espaço SubaracnóideoRESUMO
We present a case of a patient who received nitrous oxide on two occasions within a period of 8 weeks and who subsequently developed a diffuse myelopathy, characterized by upper extremity paresis, lower extremity paraplegia and neurogenic bladder. Laboratory testing revealed hyperhomocysteinaemia and low levels of vitamin B(12). Because of this uncommon clinical presentation, we analysed the patient's DNA, and found a polymorphism in the MTHFR gene that is associated with the thermolabile isoform of the 5,10-methylenetetrahydrofolate reductase enzyme, which explained the myelopathy experienced by the patient after being exposed to nitrous oxide. Soon after initiating supplementary therapy with folic acid and vitamin B(12), the neurological symptoms subsided.
Assuntos
Anestésicos Inalatórios/efeitos adversos , Metilenotetra-Hidrofolato Redutase (NADPH2)/genética , Óxido Nitroso/efeitos adversos , Polimorfismo Genético , Doenças da Medula Espinal/induzido quimicamente , Ácido Fólico/uso terapêutico , Predisposição Genética para Doença , Humanos , Hiper-Homocisteinemia/complicações , Masculino , Pessoa de Meia-Idade , Paralisia/induzido quimicamente , Complicações Pós-Operatórias , Doenças da Medula Espinal/tratamento farmacológico , Doenças da Medula Espinal/genética , Vitamina B 12/uso terapêuticoRESUMO
We report two cases of Caesarean section in patients with Marfan's syndrome where continuous subarachnoid anaesthesia failed to provide an adequate surgical block. This was possibly because of dural ectasia, which was confirmed by a computed tomography scan in both cases.