RESUMEN
OBJECTIVE: This study is aiming to determine an actual incidence and characteristics of complications in cesarean section for severe pre-eclampsia (PE) by analysis of a large cohort from a single tertiary care center according to two choices of anesthesia. METHODS: Electronic medical records of pregnant women complicated with severe PE delivered by cesarean section from January 2002 to December 2011 were retrospectively reviewed. Medical records of their corresponding neonates were also identified and reviewed. RESULTS: A total of 701 women and 740 neonates (28 twin pairs) were identified. Anesthetic techniques were spinal anesthesia (SA) (88%) and general anesthesia (GA) (12%). Total maternal and neonatal deaths were 0.3% and 1.2%, respectively. Patients in GA group had a higher incidence of coagulopathy, immediate postpartum hemorrhage, intensive care unit admission, renal failure, respiratory complications, and death (p < 0.05). Neonates born from women in GA group had a higher incidence of lower birth weight, birth asphyxia, prematurity, neonatal intensive care admission, respiratory complications, and death (p < 0.05). CONCLUSION: Spinal anesthesia can be safely administered to severely pre-eclamptic parturients undergoing cesarean section. General anesthesia is associated with more untoward outcomes, as it has been chosen in patients with more severity of the disease.
Asunto(s)
Anestesia General/estadística & datos numéricos , Anestesia Obstétrica/métodos , Anestesia Raquidea/estadística & datos numéricos , Cesárea/estadística & datos numéricos , Preeclampsia/epidemiología , Adulto , Anestesia Obstétrica/efectos adversos , Anestesia Obstétrica/estadística & datos numéricos , Anestesia Raquidea/efectos adversos , Anestesia Raquidea/métodos , Femenino , Edad Gestacional , Humanos , Incidencia , Lactante , Mortalidad Infantil , Recién Nacido de Bajo Peso , Recién Nacido , Recien Nacido Prematuro , Embarazo , Resultado del Embarazo , Centros de Atención Terciaria/estadística & datos numéricos , Tailandia/epidemiología , Adulto JovenRESUMEN
We performed a prospective, double-blinded study in 20 patients undergoing gynecologic surgery with lower abdominal incision, to investigate characteristics of intrathecal hyperbaric levobupivacaine compared with isobaric levobupivacaine. We randomly assigned them to receive 3 mL of either isobaric or hyperbaric 0.42% levobupivacaine intrathecally. We found that hyperbaric levobupivacaine, compared with isobaric levobupivacaine, spread faster to T10 level (2.8 ± 1.1 versus 6.6 ± 4.7 minutes, P = 0.039), reached higher sensory block levels at 5 and 15 minutes after injection (T8 versus L1, P = 0.011, and T4 versus T7, P = 0.027, resp.), and had a higher peak level (T4 versus T8, P = 0.040). Isobaric levobupivacaine caused a wider range of peak levels (L1 to C8) compared with hyperbaric form (T7 to T2). The level of T4 or higher reached 90% in the hyperbaric group compared with 20% in the isobaric group (P = 0.005). Our results suggest that hyperbaric levobupivacaine was more predictable for sensory block level and more effective for surgical procedures with lower abdominal approach. Hyperbaric levobupivacaine seems to be suitable, but the optimal dosage needs further investigation.
Asunto(s)
Analgésicos/administración & dosificación , Oxigenoterapia Hiperbárica , Adulto , Analgesia Epidural , Bupivacaína/administración & dosificación , Bupivacaína/análogos & derivados , Bupivacaína/uso terapéutico , Método Doble Ciego , Humanos , Inyecciones Espinales , Levobupivacaína , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
OBJECTIVE: To determine the effect of 200 µg of intravenous nitroglycerin in the release of retained placenta by controlled cord traction. METHODS: In this randomized controlled study, 40 women with a placenta retained for 30 minutes received intravenously 200 µg of nitroglycerin or a normal saline solution before umbilical cord traction was initiated. The rates of successful removal of the retained placenta in the study (n=20) and control (n=20) groups were compared, as were blood pressure, pulse rate, blood loss, and adverse effects. RESULTS: The placenta was released in only 15% and 20% of the participants in the study and control group, respectively. The remainder of the participants required general anesthesia and manual removal of the retained placenta regardless of group assignation. Blood pressure fell in significantly more women in the study group, but there were no differences in estimated blood loss or minor adverse effects. CONCLUSION: Intravenously administered nitroglycerin did not facilitate the release of retained placenta by umbilical cord traction. However, cord traction may be performed longer than 30 minutes to attempt releasing the placenta before operative manual removal is initiated.
Asunto(s)
Nitroglicerina/uso terapéutico , Retención de la Placenta/tratamiento farmacológico , Vasodilatadores/uso terapéutico , Adulto , Presión Sanguínea/efectos de los fármacos , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Inyecciones Intravenosas , Nitroglicerina/administración & dosificación , Nitroglicerina/efectos adversos , Hemorragia Posparto/etiología , Embarazo , Factores de Tiempo , Cordón Umbilical , Vasodilatadores/administración & dosificación , Vasodilatadores/efectos adversos , Adulto JovenRESUMEN
OBJECTIVE: Spinal anesthesia is commonly used for cesarean section. Its major adverse effect is hypotension. The objective of this study is to determine the incidence and risk factors of hypotension during spinal anesthesia for cesarean section. MATERIAL AND METHOD: The authors retrospectively reviewed anesthetic records of 991 patients who received spinal anesthesia for cesarean section at Siriraj Hospital. Exclusion criteria were patients with pregnancy included hypertension, received combination of spinal block with other type of anesthesia. RESULTS: The incidence of hypotension (the lowest systolic blood pressure < or = 100 mm Hg) was 76.%. The parameter with increased incidence of hypotension included patient's height < 155 cm (adjusted odd ratio (OR) 1.93, 95%CI 1.19-3.14), baseline systolic blood pressure < or = 120 mmHg (OR 2.14, 95%CI 1.53-2.99) and analgesic level > or = T5 (OR 1.83, 95%CI 1.18-2.84). CONCLUSION: The risk factors associated with increased incidence of hypotension are the patient 's height, baseline systolic blood pressure and level of blockade.
Asunto(s)
Anestesia Raquidea/efectos adversos , Cesárea , Hipotensión/etiología , Adulto , Anestésicos Locales/administración & dosificación , Presión Sanguínea , Estatura , Bupivacaína/administración & dosificación , Femenino , Hospitales , Humanos , Morfina/administración & dosificación , Narcóticos/administración & dosificación , Embarazo , Estudios Retrospectivos , Factores de Riesgo , TailandiaRESUMEN
BACKGROUND AND OBJECTIVES: Total-knee replacement (TKR) surgery is one of the most painful orthopedic procedures after surgery. Opioid has been commonly combined with a local anesthetic to improve the quality of pain relief, but the treatment has opioid-related side effects. This study compared the cost effectiveness of patient-controlled epidural analgesia (PCEA) with 0.0625% bupivacaine plus fentanyl (BF) 3 microg/mL versus 0.15% ropivacaine alone (R) during the first 48 hours after TKR procedure. METHODS: This prospective randomized double-blinded study was performed on 70 patients who underwent unilateral TKR procedure and received either BF or R after surgery. Visual analog scale (VAS) pain score at rest and upon movement, side effects, and cost of treatment were compared. RESULTS: Overall pain at rest and upon movement between groups was not significantly different (P = 0.58, 95% CI = 4.4 to -7.8 and P = 0.8, 95% CI = 6.4 to -8.2, respectively). Patients in the BF group experienced more pruritus and had more vomiting episodes than those in the R group (P = .015), whereas no difference occurred in other side effects. Nevertheless, patient satisfaction with pain management was higher in the BF group compared with that in the R group. In addition, pain treatment with bupivacaine and fentanyl was 18% less costly compared with ropivacaine alone. CONCLUSIONS: Considering the economic evaluation, we conclude that PCEA with 0.0625% bupivacaine plus fentanyl 3 microg/mL is more cost effective and provides more patient satisfaction than PCEA with ropivacaine alone. However, use of epidural ropivacaine alone causes fewer opioid-related side effects, particularly pruritus and vomiting.
Asunto(s)
Amidas/economía , Analgesia Epidural/economía , Analgesia Controlada por el Paciente/economía , Artroplastia de Reemplazo de Rodilla , Bupivacaína/economía , Fentanilo/economía , Anciano , Amidas/administración & dosificación , Amidas/efectos adversos , Analgesia Epidural/métodos , Anestésicos Combinados/administración & dosificación , Anestésicos Combinados/efectos adversos , Anestésicos Combinados/economía , Anestésicos Intravenosos/administración & dosificación , Anestésicos Intravenosos/efectos adversos , Anestésicos Intravenosos/economía , Anestésicos Locales/administración & dosificación , Anestésicos Locales/efectos adversos , Anestésicos Locales/economía , Bupivacaína/administración & dosificación , Bupivacaína/efectos adversos , Análisis Costo-Beneficio/métodos , Método Doble Ciego , Femenino , Fentanilo/administración & dosificación , Fentanilo/efectos adversos , Humanos , Masculino , Dimensión del Dolor/métodos , Dolor Postoperatorio/prevención & control , Satisfacción del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/inducido químicamente , Estudios Prospectivos , RopivacaínaRESUMEN
In this randomized, multicenter study we compared the hemodynamic effects of spinal and epidural anesthesia for cesarean delivery in severely preeclamptic patients. The epidural group (n = 47) received 2% lidocaine with epinephrine 1:400,000, 18-23 mL, followed by 3 mg of morphine after delivery. The spinal group (n = 53) received 2.2 mL of 0.5% hyperbaric bupivacaine plus 0.2 mg morphine. We hypothesized that the lowest MAP (mean arterial blood pressure, the primary outcome) during the delivery period would have to be at least 10 mm Hg less in the spinal group to be of clinical importance. We found that there was a statistically significant difference in MAP, with more patients in the spinal group exhibiting hypotension (P < 0.001). Although the incidence of hypotension (systolic arterial blood pressure, SAP < or =100 mm Hg) was more frequent in the spinal group than in the epidural group (51% versus 23%), the duration of significant hypotension (SAP < or =100 mm Hg) was short (< or =1 min) in both groups. There was more use of ephedrine in the spinal group than in the epidural group (median, 6 versus 0 mg) but hypotension was easily treated in all patients. Neonatal outcomes assessed by Apgar scores and the umbilical arterial blood gas analysis were similar in both groups. Adverse neonatal outcomes (5-min Apgar score < 7 and umbilical arterial blood pH < 7.20) were found in only 2 premature newborns (weight < 1500 g) who were born without maternal hypotension after regional anesthesia. We conclude that the results of this large prospective study support the use of spinal anesthesia for cesarean delivery in severely preeclamptic patients.
Asunto(s)
Anestesia Epidural , Anestesia Obstétrica , Anestesia Raquidea , Cesárea , Preeclampsia/fisiopatología , Adulto , Puntaje de Apgar , Peso al Nacer/fisiología , Análisis de los Gases de la Sangre , Presión Sanguínea/fisiología , Método Doble Ciego , Femenino , Hemodinámica/efectos de los fármacos , Hemodinámica/fisiología , Humanos , Recién Nacido , EmbarazoRESUMEN
This prospective, double-blind, randomized, controlled trial was performed to evaluate the antiemetic effectiveness and side effects of adding droperidol to morphine delivered via a patient-controlled analgesia (PCA) device in 94 women undergoing transabdominal hysterectomy with a standardized anesthetic regimen. They were randomly allocated to receive postoperative PCA as either bolus doses of morphine I mg or a combination of morphine 1 mg and 0.0625 mg droperidol with a lockout interval of 5 minutes and no continuous infusion. The incidence of nausea 6-18 hours postoperatively and 18-24 hours postoperatively was significantly lower in the morphine and droperidol group than in the morphine only group and its severity 2-6 hours, 6-18 hours, and 18-24 hours postoperatively was significantly lower. The number needed to treat to prevent nausea comparing the morphine only group at 6-18 and at 18-24 hours postoperatively were 4 and 4 (95% CI 2-27 and 2-11, respectively). The amount of morphine used 6-18 hours postoperatively in the droperidol group was lower than in the morphine only group. Although the incidence of vomiting and the amount of rescue antiemetics were lower in the morphine and droperidol group, the difference was not statistically significant. Postoperative pain scores were not different between the groups. No patients were oversedated. A series of extrapyramidal reactions were observed in one patient in the morphine and droperidol group. The drug and consumable item cost was not different between the groups. We conclude that droperidol added to morphine in PCA reduces nausea. The appropriate dose of droperidol should be further investigated to reduce the incidence of vomiting.
Asunto(s)
Analgesia Controlada por el Paciente/métodos , Analgésicos Opioides/efectos adversos , Antieméticos/uso terapéutico , Droperidol/uso terapéutico , Histerectomía , Morfina/efectos adversos , Náusea y Vómito Posoperatorios/prevención & control , Adulto , Analgesia Controlada por el Paciente/efectos adversos , Distribución de Chi-Cuadrado , Método Doble Ciego , Femenino , Humanos , Persona de Mediana Edad , Estudios Prospectivos , Estadísticas no Paramétricas , Resultado del TratamientoRESUMEN
UNLABELLED: We conducted a randomized, double blinded, placebo controlled trial to evaluate the effectiveness of EMLA cream together with intraperitoneal lidocaine for pain relief in postpartum tubal ligation. In a factorial designed study, 90 postpartum patients were randomly assigned to have 5 g of EMLA or placebo cream applied to the skin in 2 groups of 45 patients and to have intraperitoneal instillation of 20 ml of either 1 per cent, 2 per cent lidocaine or normal saline in 3 groups of 30 patients. A numerical rating pain score (0-10) was used during skin check, skin infiltration and uterine tube manipulation. The pain scores were significantly lower in the EMLA group as compared with the placebo group during the skin forceps check (p < 0.001) and during local skin infiltration (p < 0.05). The pain scores were also significantly lower during intraabdominal manipulation in the group using either 1 per cent or 2 per cent intraperitoneal lidocaine as compared with the group using normal saline (p < 0.001), but no difference was found between the groups using 1 per cent and 2 per cent lidocaine. IMPLICATIONS: Five g of EMLA cream applied to the skin together with 20 ml of 1 per cent lidocaine instilled into the abdominal cavity effectively decrease intraoperative pain in patients undergoing postpartum tubal sterilization under local anesthesia.
Asunto(s)
Anestésicos Locales/administración & dosificación , Complicaciones Intraoperatorias/tratamiento farmacológico , Lidocaína/administración & dosificación , Dolor/tratamiento farmacológico , Prilocaína/administración & dosificación , Adulto , Distribución de Chi-Cuadrado , Método Doble Ciego , Femenino , Humanos , Inyecciones Intraperitoneales , Combinación Lidocaína y Prilocaína , Pomadas , Periodo Posparto , Embarazo , Estadísticas no Paramétricas , Esterilización Tubaria , Resultado del TratamientoRESUMEN
UNLABELLED: To investigate the effectiveness of intravenous lornoxicam and morphine with the preemptive effects of ropivacaine local skin infiltration and peritoneal instillation in reducing postoperative pain after transabdominal hysterectomy, a randomized, double blinded, placebo-controlled study was done in 88 patients undergoing transabdominal hysterectomy under general anesthesia. The patients were allocated into 4 groups to receive: (group A) only intravenous morphine 10 mg; (group B) intravenous morphine 10 mg and lornoxicam 16 mg; (group C) intravenous morphine 10 mg, lornoxicam 16 mg with 0.5 per cent ropivacaine local skin infiltration before skin incision and 1 per cent ropivacaine instillation before peritoneal incision; (group D) intravenous morphine 10 mg, lornoxicam 16 mg with 1 per cent ropivacaine instillation after peritoneal closure and 0.5 per cent ropivacaine local skin infiltration before skin closure. Pain was assessed by patients using visual analog scales (VAS) at 2, 6, 12, 18, 24, 48 hours after surgery. Time to first analgesic requirement and morphine requirement during the first 6 h were significantly lower in the groups using lornoxicam (group B, C, D) as compared with the group using only morphine (group A). However there was no significant difference between group B and group C or group D which means that the additional analgesic effects of using local anesthetic infiltration and instillation either before (pre-emptive) or after the incision could not be seen in this study. IMPLICATION: Intravenous 16 mg of lornoxicam with 10 mg of morphine significantly reduced postoperative pain during the first 6 h after abdominal hysterectomy. Additional effects of using local anesthetic wound infiltration to the use of lornoxicam could not be demonstrated.