Dosis analgésica intratecal única para control del dolor de parto: ¿Es una alternativa útil de la analgesia epidural?

Dosis analgésica intratecal única para control del dolor de parto: ¿Es una alternativa útil de la analgesia epidural? Single-dose intrathecal analgesia to control labour pain: is it a useful alternative to epidural analgesia? Minty RG, Kelly L, Minty A, Hammett DC. Northern Ontario School of Medicine, Sioux Lookout.rminty@gosiouxlookout.com Can Fam Physician. 2007 Mar;53(3):437-42. Abstract OBJECTIVE: To examine the safety and efficacy of single-dose spinal analgesia (intrathecal narcotics [ITN]) during labour. QUALITY OF EVIDENCE: MEDLINE was searched and the references of 2 systematic reviews and a meta-analysis were reviewed to find articles on obstetric analgesia and pain measurement. The 33 articles selected included 14 studies, 1 meta-analysis, and 2 systematic reviews, all providing level I evidence. MAIN MESSAGE: The literature supports use of ITN as a safe and effective alternative to epidural anesthesia. The recent decrease in rates of episiotomies and use of forceps during deliveries means patients require less dense perineal anesthesia. The advantage of single-dose ITN is that fewer physicians and nurses are needed to administer it even though its safety and effectiveness are comparable with other analgesics. Use of ITN is associated with a shorter first stage of labour and more rapid cervical dilation. A combination of 2.5 mg of bupivacaine, 25 microg of fentanyl, and 250 microg of morphine intrathecally usually provides a 4-hour window of acceptable analgesia for patients without complications not anticipating protracted labour. The evolution in dosing of ITN warrants a re-examination of its usefulness in modern obstetric practice. CONCLUSION: Physicians practising modern obstetrics in rural and small urban centres might find single-dose ITN a useful alternative to parenteral or epidural analgesia for appropriately selected patients. http://www.cfp.ca/cgi/reprint/53/3/437  La morfina intratecal reduce el dolor incidental durante la analgesia epidural para el parto. Intrathecal morphine reduces breakthrough pain during labour epidural analgesia. Vasudevan A, Snowman CE, Sundar S, Sarge TW, Hess PE. Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA. Br J Anaesth. 2007 Feb;98(2):241-5. Epub 2007 Jan 8. Abstract BACKGROUND: When using the combined spinal-epidural (CSE) technique for labour analgesia, parturients often experience breakthrough pain after the spinal medication has receded. We tested the hypothesis that a small dose of intrathecal morphine would reduce breakthrough pain. METHODS: This was a randomized, double-blind, placebo-controlled trial. Subjects were randomized to receive either 100 microg of morphine (MS) or placebo (PLCB) with the spinal injection of bupivacaine and fentanyl. Assessments included need for supplementation during labour analgesia, use of pain medications for 24 h after delivery, and side-effects. The primary end-point was the rate of breakthrough pain. RESULTS: Sixty subjects were enrolled, 55 subjects completed the trial. The MS group had a significantly lower rate of breakthrough pain than the PLCB group [0.6 (0.6) vs 1.1 (0.8) episodes per patient; P < 0.01], and longer time to first episode of breakthrough pain (300 vs 180 min; P = 0.03). The MS group used 75% less opioid medications during the subsequent 24 h, but had a 17% incidence of nausea. CONCLUSIONS: The addition of small dose of morphine to the spinal component of the CSE technique improved the effectiveness of epidural labour analgesia and reduced the need for pain medications over 24 h, but resulted in a small increase in nausea. http://bja.oxfordjournals.org/content/98/2/241.full.pdf+html

Atentamente Dr. Benito Cortes-Blanco  Anestesiología y Medicina del Dolor www.anestesia-dolor.org

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