sábado, 12 de mayo de 2012

Mas sobre obesidad y embarazo

Parturienta con obesidad mórbida: retos para el anestesiólogo, incluyendo el manejo de la vía aérea difícil. ¿Qué hay de nuevo? 
Morbidly obese parturient: Challenges for the anaesthesiologist, including managing the difficult airway in obstetrics. What is new?
Rao DP, Rao VA.
Department of Anaesthesiology, Siddhartha Medical College, Government General Hospital, Government of Andhra Pradesh, Vijayawada, India.
Indian J Anaesth. 2010 Nov;54(6):508-21.
The purpose of this article is to review the fundamental aspects of obesity, pregnancy and a combination of both. The scientific aim is to understand the physiological changes, pathological clinical presentations and application of technical skills and pharmacological knowledge on this unique clinical condition. The goal of this presentation is to define the difficult airway, highlight the main reasons for difficult or failed intubation and propose a practical approach to management Throughout the review, an important component is the necessity for team work between the anaesthesiologist and the obstetrician. Certain protocols are recommended to meet the anaesthetic challenges and finally concluding with "what is new?" in obstetric anaesthesia.
Las dosis de bupivacaína intratecal para cesárea es similar en obesas y no obesas 
Dose requirement of intrathecal bupivacaine for cesarean delivery is similar in obese and normal weight women.
Lee Y, Balki M, Parkes R, Carvalho JC.
Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Ontario, Canada.
Rev Bras Anestesiol. 2009 Nov-Dec;59(6):674-83.
BACKGROUND AND OBJECTIVES: The effect of BMI on the spread of intrathecal bupivacaine is controversial. This study assessed the ED95 of intrathecal bupivacaine for elective cesarean delivery in obese and normal weight women. METHODS: We studied normal weight (BMI < 25 kg x m(-2)) and obese (BMI > 30 kg x m(-2)) women with singleton term pregnancies undergoing elective cesarean delivery. The study was conducted as a single blinded, up-down sequential allocation study (modified by the Narayana rule). All patients received a combined spinal-epidural anesthesia with a variable intrathecal dose of hyperbaric 0.75% bupivacaine, plus fentanyl 10 microg and morphine 100 microg. The first patient received 9 mg of bupivacaine. Supplemental anesthesia was provided through the epidural catheter if required. The primary outcome was successful analgesia, defined as a sensory block to at least T6, and no request for supplemental anesthesia. The ED95 for the satisfactory outcome was determined by a logistic model with non-log-transformed doses. RESULTS: Twenty-four normal weight and sixteen obese patients were enrolled. The estimated ED95 for all forty patients was 12.92 mg (95% CI: 11.49 to 34.77). The estimated ED95 for the normal weight and the obese subgroups were similar at 12.78 mg (95% CI: 10.75 to + infinity) and 11.86 mg (95%CI: 11.31 to 15.61), respectively. CONCLUSIONS: If single shot spinal anesthesia is used for cesarean delivery, obese and normal weight patients should receive similar doses of hyperbaric bupivacaine. Although in our study the effective dose 95% could not be precisely determined, it is possible to state that it is at least 11.49 mg.
Abordando la obesidad en el embarazo: ¿Que recomiendan los obstetras? 
Addressing obesity in pregnancy: what do obstetric providers recommend?
Herring SJ, Platek DN, Elliott P, Riley LE, Stuebe AM, Oken E.
Center for Obesity Research and Education, Temple University School of Medicine, Philadelphia 19140, Pennsylvania, USA.Sharon_Herring@post.harvard.edu
J Womens Health (Larchmt). 2010 Jan;19(1):65-70.
OBJECTIVE: Maternal obesity is associated with adverse pregnancy outcomes. To improve outcomes, obstetric providers must effectively evaluate and manage their obese pregnant patients. We sought to determine the knowledge, attitudes, and practice patterns of obstetric providers regarding obesity in pregnancy.METHODS: In 2007-2008, we surveyed 58 practicing obstetricians, nurse practitioners, and certified nurse-midwives at a multispecialty practice in Massachusetts. We administered a 26-item questionnaire that included provider self-reported weight, sociodemographic characteristics, knowledge, attitudes, and management practices. We created an 8-point score for adherence to 8 practices recommended by the American College of Obstetricians and Gynecologists (ACOG) for the management of obese pregnant women. RESULTS: Among the respondents, 37% did not correctly report the minimum body mass index (BMI) for diagnosing obesity, and most reported advising gestational weight gains that were discordant with 1990 Institute of Medicine (IOM) guidelines, especially for obese women (71%). The majority of respondents almost always recommended a range of weight gain (74%), advised regular physical activity (74%), or discussed diet (64%) with obese mothers, but few routinely ordered glucose tolerance testing during the first trimester (26%), planned anesthesia referrals (3%), or referred patients to a nutritionist (14%). Mean guideline adherence score was 3.4 (SD 1.9, range 0-8). Provider confidence (beta = 1.0, p = 0.05) and body satisfaction (beta = 1.5, p = 0.02) were independent predictors of higher guideline adherence scores. CONCLUSIONS: Few obstetric providers were fully compliant with clinical practice recommendations, defined obesity correctly, or recommended weight gains concordant with IOM guidelines. Provider personal factors were the strongest correlates of self-reported management practices. Our findings suggest a need for more education around BMI definitions and weight gain guidelines, along with strategies to address provider personal factors, such as confidence and body satisfaction, that may be important predictors of adherence to recommendations for managing obese pregnant women.
Dr. Benito Cortes-Blanco
Anestesiología y Medicina del Dolor
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