Técnicas analgésicas en partos inducidos con cervix desfavorable: estudio comparativo

Tesis doctoral inédita leida en la Universidad Autónoma de Madrid. Departamento de Cirugía. Fecha de lectura: 9 de Diciembre de 200

Estudio observacional de la analgesia epidural para trabajo de parto: Complicaciones de la técnica en 5.895 embarazadas

Objectives: a) To determine the incidence of complications related to regional analgesia technique during the procedure, during dilatation and after delivery; and b) to ascertain whether post-delivery complications related to the analgesic technique are more frequent when the combined epidural-subarachnoid (CES) technique is used, compared to epidural analgesia. Material and method: We conducted a descriptive and analytical observational study. The study population included all women that demanded regional analgesia at the Epidural Analgesia Unit of our Hospital (5,895 pregnant women) and fulfilled all the inclusion criteria, from January 1, 2002 to January 1, 2003. Techniques used for the management of labour pain were epidural analgesia and combined epidural-subarachnoid technique. Results: The most frequent complication associated to the technique was paresthesia (43.5%) followed by hematic puncture (5.9%). Unintentional dura mater puncture occurred in 0.6%. The most frequent complications during the dilatation period were itching (11.4%) and lateralized analgesia (9%). The most frequent complications during the post-delivery period were back pain (9.8%) and headache (2%). Complications were, in general, more frequent among pregnant women undergoing the CES technique compared to the standard epidural analgesia. Conclusions: Complications that can appear due to this type of analgesia range from rare but potentially dangerous complications if they go unnoticed (such as intravascular injection of local anesthetics or total spine blockade) to more common complications such as paresthesia with still unknown long-term effects. Other complications, such as back pain or urinary retention, require controlled and randomized prospective studies on a high number of patients in order to clarify their potential association with epidural analgesia. Post-dural puncture headache appears in half the cases of unnoticed dural puncture, this usually occurring in 1.5% of pregnant women undergoing epidural analgesia technique. In our study, however, it occurred with a less-than-expected frequency, despite being a teaching hospital in Anesthesiology. Further extensive studies are also required in order to determine the actual incidence of complications, such as epidural hematoma or epidural abscess.Objetivos: a) Conocer la incidencia de las complicaciones relacionadas con la técnica de analgesia regional durante la realización de la técnica, durante la dilatación y en el postparto; y b) conocer si las complicaciones del postparto relacionadas con la técnica analgésica son más frecuentes cuando se realiza la técnica combinada epidural-subaracnoidea (CES) en comparación con la analgesia epidural. Material y método: Hemos realizado un estudio observacional descriptivo y analítico. Como sujetos del estudio hemos incluido a todas las mujeres que solicitaron la administración de analgesia regional a la Unidad de Analgesia Epidural de nuestro hospital (5.895 embarazadas) y cumplían los criterios de inclusión, en un periodo de tiempo que empieza en el 1 de enero del año 2002 y termina el 1 de enero del año 2003. Las técnicas empleadas para el control del dolor del trabajo del parto fueron la analgesia epidural y la técnica combinada epidural-subaracnoidea. Resultados: La complicación que más frecuentemente apareció durante la realización de la técnica fueron las parestesias (43,5%) seguido de la punción hemática (5,9%). La punción no intencionada de la duramadre ha ocurrido en el 0,6%. Las complicaciones que más frecuentemente aparecieron durante el periodo de dilatación fue el prurito (11,4%) y la analgesia lateralizada (9%). La complicación más frecuente del periodo postparto fue el dolor de espalda (9,8%) y la cefalea (2%). Las complicaciones en general han sido significativamente más frecuentes en las embarazadas a las que se les aplicó la técnica CES, en comparación con la analgesia epidural convencional. Conclusiones: Las complicaciones que pueden aparecer debido a este modo de analgesia van desde unas poco frecuentes y potencialmente peligrosas si pasan desapercibidas (como la inyección intravascular de anestésicos locales o el bloqueo espinal total) a otras más frecuentes como las parestesias, con una repercusión a largo plazo todavía desconocida. Otras complicaciones como el dolor de espalda o la retención urinaria, necesitan de estudios prospectivos controlados y aleatorizados con gran número de pacientes para aclarar la posible relación con la analgesia epidural. La cefalea postpunción dural aparece en la mitad de los casos de punciones durales inadvertidas, que suele ocurrir en el 1,5% de las gestantes a las que se les realiza la técnica de analgesia epidural, aunque en nuestro estudio ha ocurrido con una frecuencia menor a la esperada a pesar de ser un hospital docente en Anestesiología. También se necesitan estudios con muchos pacientes para conocer la incidencia real de complicaciones como el hematoma epidural o el absceso epidural

Reducing by 50% the incidence of maternal hypotension during elective caesarean delivery under spinal anesthesia: Effect of prophylactic ondansetron and/or continuous infusion of phenylephrine - a double-blind, randomized, placebo controlled trial

Background: Prophylactic administrations of ondansetron or phenylephrine have been reported to provide a protective effect against hypotension in women undergoing cesarean delivery under spinal anesthesia (SA). The main hypothesis is that ondansetron improves the hemodynamic response, especially combined with phenylephrine infusion. Methods: This prospective, double-blind, randomized, placebo-controlled study included 265 healthy pregnant women scheduled for elective cesarean delivery under SA. Women were randomly allocated into four groups to receive either placebo (control), ondansetron (O) 8 mg intravenously before induction of SA, phenylephrine infusion (50 mcg/min) (P) or ondansetron plus phenylephrine (OP). Demographic, obstetric, intraoperative timing, and anesthetic variables were assessed at 16 time points. Anesthetic variables assessed included blood pressure, heart rate, oxygen saturation, nausea, vomiting, electrocardiographic changes, skin flushing, discomfort or pruritus, and vasopressor requirements. Results: There were differences (P = 0.0001) in the number of patients with hypotension (50.8% control, 44.6% O, 20.9% P, 25.0% OP), the percentage of time points (P = 0.0001) with systolic hypotension per patient (17.4% control, 8.7% O, 2.1% P, 6.7% OP) and the number of patients requiring supplementary boluses of ephedrine (P = 0.003), phenylephrine (P = 0.017) or atropine (P = 0.0001). Conclusions: A 50 μg/min phenylephrine infusion reduces by 50%, the incidence of maternal hypotension compared with placebo, but infusions of phenylephrine are still not routine in our environment. Prophylactic ondansetron 8 mg might be considered in this situation, because it does not reduce the incidence of maternal hypotension but diminishes its severity, reducing the number of hypotensive events per patient by 50%

‘Walking epidural’: comparison of the analgesic efficacy of levobupivacaine 0.0625% + fentanyl 2mcg/mL versus ropivacaine 0.075% + fentanyl 2mcg/mL

Abstract Introduction Epidural infusion with low local anesthetic concentrations with opiates decrease the severity of the motor blockade associated. The present study aims to compare the analgesic efficacy and the motor blockade between two local anesthetic epidural infusions: levobupivacaine 0.0625% + fentanyl 2mcg/mL versus ropivacaine 0.075% + fentanyl 2mcg/mL. Materials and methods In a single-blind prospective randomized study, 60 laboring parturient had continuous epidural analgesia as follows: 30 of them received levobupivacaine 0.0625% + fentanyl 2mcg/mL and 30 of them received ropivacaine 0.075% + fentanyl 2mcg/mL and rates of infusion were adjusted to the height. Analgesic, motor blockade and satisfaction records were collected as well as maternal and neonate adverse events. Results After 2 h of the catheter placement, patients who received levobupivacaine showed a mean VAS of 3.2 [1.8–4.6] versus 1.8 [1.2–2.5] (p = 0.05) in patients who received ropivacaine. In addition, patients who received levobupivacaine showed a punctuation in Bromage scale of 0.0 [0.0–1.0] versus 0.0 [0.0–0.0] (p = 0.04) in patients who received ropivacaine. Finally, the parturient who received levobupivacaine scored a mean satisfaction index of 8.1 [7.3–8.9] versus 9.3 [8.7–9.8] (p = 0.02) in those who received ropivacaine. We did not register maternal nor neonate adverse events. Conclusion Both infusions (levobupivacaine 0.0625% + fentanyl 2mcg/mL and ropivacaine 0.075% + fentanyl 2mcg/mL) are effective for labor analgesia. However, ropivacaine would present a better pharmacodynamic profile with less motor blockade and decreased need for analgesic rescue hence improving patient’s satisfaction