domingo, 4 de enero de 2015

Aditivos espinales en cesárea / Spinal Additives for Cesarean Section

Comparación de dexmedetomidina espinal versus fentanilo espinal con bupivacaína epidural en analgesia obstétrica combinada 

A comparison of intrathecal dexmedetomidine verses intrathecal fentanyl with epidural bupivacaine for combined spinal epidural labor analgesia .
Dilesh P K, Eapen S, Kiran S, Chopra V.
J Obstet Anaesth Crit Care [serial online] 2014 [cited 2014 Nov 1];4:69-74.
Context: Combined spinal epidural (CSE) analgesia technique is effective for labor analgesia and various concentrations of bupivacaine and lipophilic opioids like fentanyl have been studied. Dexmedetomidine is a highly selective alpha 2 adrenoreceptor agonist with analgesic properties and has been used intrathecally with bupivacaine for prolonged postoperative analgesia. Recent reviews have shown that it is highly lipophilic and does not cross placenta significantly. Aim: The aim of this study is to compare the duration and quality of analgesia, maternal and neonatal outcomes after CSE labor analgesia with intrathecal dexmedetomidine and intrathecal fentanyl followed by epidural bupivacaine. Settings and Design: A randomized observational study with 112 parturients in a tertiary care hospital. Materials and Methods: 112 parturients were randomly divided to two groups. Group D (n = 58) received dexmedetomidine 10 μg and group F (n = 54) received fentanyl 20 μg intrathecally for labor analgesia. The time of onset, time to maximum analgesia, duration and quality of analgesia were noted. Maternal parameters of heart rate, noninvasive blood pressure, motor block and side-effects of pruritus, nausea and vomiting were recorded. Neonatal outcome in terms of mode of delivery, neonatal APGAR score, time to first cry, need for resuscitation, umbilical cord blood pH, initiation of breast feeding, Neurologic and Adaptive Capacity Score at 24 h and exclusivity of breast feeding at 6 weeks were recorded. Results: Duration of analgesia was 160.54 ± 52.4 min with dexmedetomidine and 124.1 ± 46.93 min with fentanyl (P < 0.001). Visual analog score (VAS) recorded at maximal analgesia was significantly lesser in the fentanyl group compared to dexmedetomidine group, denoting a significantly deeper level of analgesia with fentanyl. However, all the mothers in the dexmedetomidine group achieved a VAS <3 and were satisfied with the quality of analgesia. About 74% patients in the fentanyl group experienced pruritus after intrathecal injection whereas none of the mothers in dexmedetomidine group experienced pruritus (P < 0.001). There were no significant differences in neonatal outcome between the two groups. Conclusion: 10 μg dexmedetomidine intrathecally provides a longer duration of analgesia with lesser incidence of pruritus compared to 20 μg fentanyl intrathecally for CSE labor analgesia with comparable neonatal side-effects.
Keywords: Combined spinal epidural labor analgesia, dexmedetomidine, fentanyl;year=2014;volume=4;issue=2;spage=69;epage=74;aulast=Dilesh;type=2

Efecto ahorrador de bupivacaína con el midazolam intratecal en anestesia subaracnoidea para cesárea.

Bupivacaine sparing effect of intrathecal midazolam in sub-arachnoid block for cesarean section
Sanwal MK, Baduni N, Jain A..
J Obstet Anaesth Crit Care [serial online] 2013 [cited 2014 Nov 1];3:27-31.
Background: Hypotension during subarachnoid block for caesarean section (CS) is the most common and potentially dangerous complication. Bupivacaine has been implicated for this effect in a dose dependent manner. Hypotension can be prevented by using lower doses of bupivacaine with intrathecal midazolam as an adjuvant drug, though the optimum dose-ratio of bupivacaine with midazolam remains unaddressed. Materials and Methods: A prospective, randomized, double-blind study was conducted enrolling 120 consecutive ASA grade I obstetric patients undergoing elective CS in a tertiary care hospital. A baseline supine position noninvasive blood pressure (BP) was recorded. All patients were preloaded with 500 ml of lactated Ringers' solution. Varying doses of 0.5% hyperbaric bupivacaine were used (7.5mg in group II, 6mg in group III and 5mg in group IV), in combination with 2mg midazolam in each group. Appropriately matched controls were given 11mg bupivacaine alone (Group I). Intra-operatively, BP was measured at every 2 minutes till 30 minutes and every 10 minutes thereafter. Hypotensive episodes [Systolic BP (SBP) < 100 mmHg] were recorded in each group. Quality of surgical anesthesia was graded as "excellent", "good" and "poor" as per the validated scoring system. The outcomes in different groups were compared by one-way ANOVA . intra group comparisons were done with t test. Results: All the four groups had 30 patients each. The incidence of hypotension was significantly lower in the groups using low-dose bupivacaine and midazolam, with a lesser fall in SBP than group I. Onset of sensory and motor blocks, and quality of surgical anesthesia were unaffected in group II while significant deterioration was noticed in groups III and IV. Conclusion: We found that 7.5 mg bupivacaine with 2 mg midazolam is the optimum dose ratio combination to be used in subarachnoid block for caesarean section.
Keywords: Cesarean section, intrathecal, midazolam, sub-arachnoid block;year=2013;volume=3;issue=1;spage=27;epage=31;aulast=Sanwal;type=2

Aditivos espinales en raquianestesia para operación cesárea

Spinal Additives in Subarachnoid Anaesthesia for Cesarean Section
Hala M. Goma, Juan C. Flores-Carrillo and Víctor Whizar-Lugo
Topics in Spinal Anaesthesia

Cesarean section is among the most commonly performed surgeries in women and neuroaxial anaesthesia is the technique of choice for this procedure. Although numerous side effects related to obstetric anaesthesia had been described, [1, 2, 3, 4] subarachnoid anaesthesia has a clear tendency to be used more often than epidural and combined spinal-epidural technique. It is safe, easy to perform, effective, low failure rate, no systemic local anaesthetic toxicity, inexpensive, prevents aspiration pneumonia, and has a high rate of maternal satisfaction. [5,6, 7] Produces a deep anaesthesia, inhibits the stress response to surgery, blunts the autonomic and somatic responses to pain, and facilitate breathing, coughing, sighing and early ambulation [8, 9] Finally, efferent sympathetic blockade results in increased blood flow to the blocked area resulting in better wound healing. It also reduces the risk of deep vein thrombosis and thromboembolism.

Anestesiología y Medicina del Dolor

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