Anesteziološke tehnike u jednodnevnoj kirurgiji za zahvate kod displazije vrata maternice – iskustva u KBC-u Sestre milosrdnice

Danas su anestezija i analgezija tako sigurne i učinkovite da se kirurški zahvati kod displazije vrata maternice mogu obavljati unutar jednodnevne kirurgije. Anesteziološke tehnike u jednodnevnoj kirurgiji povezane su sa značajno manje morbiditeta i mortaliteta. Do 2015. godine svi su se kirurški zahvati kod displazije vrata maternice u Kliničkom bolničkom centru Sestre milosrdnice u Zagrebu radili u općoj anesteziji, a prosječni boravak u bolnici trajao je duže od 30, a kraće od 72 sata. U Klinici za ženske bolesti i porodništvo proveli smo retrospektivno istraživanje u periodu od siječnja 2015. do prosinca 2019. godine, budući da su se od tada zahvati konizacije započeli izvoditi u lokalnoj anesteziji. Proučavali smo učestalost opće i regionalne anestezije u odnosu na vrstu konizacije, učestalost vrste anestezije u odnosu na dobnu skupinu i procjenu rizika bolesnica za anesteziju, te duljinu hospitalizacije u odnosu na vrstu kirurškog zahvata. U periodu od 2015. do 2019. godine zabilježen je stalni porast udjela lokalne anestezije u ukupnom broju elektrodijatermijski odstranjenih transformacijskih zona velikom petljom (engl. Large loop excision of the transformation zone) za 36,5% (49/104 zahvata 2015. u odnosu na 112/134 zahvata 2019.). Od listopada 2018., kada je uveden spinalni blok kao metoda anestezije za konizaciju hladnim nožem, do prosinca 2019. godine udio spinalnog bloka u ukupnom broju konizacija hladnim nožem porastao je za 17,3% (2/65 zahvata 2018. u odnosu na 11/54 zahvata 2019.). Istraživanje prikazuje analizu razlike pojavnosti anestezioloških tehnika ovisno o vrsti kirurškog zahvata, procjeni rizika i životnoj dobi bolesnica za anesteziju kod displazije vrata maternice te duljinu hospitalizacije u odnosu na vrstu konizacije

Epiduralna analgezija u porodništvu - proturječja

Labor pain is one of the most severe pains. Labor is a complex and individual process with varying maternal requesting analgesia. Labor analgesia must be safe and accompanied by minimal amount of unwanted consequences for both the mother and the child, as well as for the delivery procedure. Epidural analgesia is the treatment that best meets these demands. According to the American Congress of Obstetrics and Gynecology and American Society of Anesthesiologists, mother’s demand is a reason enough for the introduction of epidural analgesia in labor, providing that no contraindications exist. The application of analgesics should not cease at the end of the second stage of labor, but it is recommended that lower concentration analgesics be then applied. Based on the latest studies, it can be claimed that epidural analgesia can be applied during the major part of the first and second stage of labor. According to previous investigations, there is no definitive conclusion about the incidence of instrumental delivery, duration of second stage of labor, time of epidural analgesia initiation, and long term outcomes for the newborn. Cooperation of obstetric and anesthesiology personnel, as well as appropriate technical equipment significantly decrease the need of instrumental completion of a delivery, as well as other complications encountered in the application of epidural analgesia. Our hospital offers 24/7 epidural analgesia service. The majority of pregnant women in our hospital were aware of the advantages of epidural analgesia for labor, however, only a small proportion of them used it, mainly because of inadequate level of information.Bol kod porođaja smatra se jednom od najjačih boli. Porođaj je složen i individualan proces s različitim željama žena za analgezijom. Analgezija u porođaju mora biti sigurna i s minimalnim neželjenim posljedicama za majku, dijete i za tijek porođaja. Tim uvjetima najbolje udovoljava epiduralna analgezija (EA). Prema American College of Obstetrics and Gynecology i American Society of Anesthesiologists za primjenu EA u porođaju dovoljna je želja rodilje ako ne postoji kontraindikacija. Davanje analgetika ne treba prestati na kraju drugog porođajnog doba, ali se tada preporučuju niske koncentracije lokalnog anestetika te dodavanje adjuvansa. Novije studije ukazuju na to da se EA može primijeniti u najvećem dijelu prvog i drugog porođajnog doba. Bez obzira na dosadašnja iskustva i istraživanja ne postoji slaganje oko učestalosti instrumentalnog dovršenja porođaja, trajanja drugog porođajnog doba uz EA i vremena uvođenja EA te dugoročnog utjecaja na dijete. Dobra suradnja opstetričkog i anesteziološkog osoblja i dobra tehnička opremljenost znatno smanjuju potrebu za instrumentalnim dovršenjem porođaja, kao i druge komplikacije EA. Naša bolnica nudi EA za olakšani porođaj tijekom 24 sata. Većina trudnica je svjesna prednosti primjene EA za vaginalni porođaj, međutim, samo mali broj trudnica iskoristi tu mogućnost, uglavnom zbog nedovoljne obaviještenosti o toj metodi

Dileme oko izbora anestezije za elektivni carski rez u trudnica s miotoničnom distrofijom tip 2 i sumnjom na von Willebrandovu bolest: prikaz slučaja

With advancement of medicine in the field of diagnostics and treatment of women suffering from certain genetic disorders, more and more women have attained reproductive age and desired fertility. Maintaining pregnancy, as well as bringing it to an end poses a real challenge not only for obstetricians, but also for anesthesiologists involved in the procedure. In our case report, we describe anesthetic management of a female patient suffering from myotonic dystrophy type 2 and suspected von Willebrand’s disease, and undergoing elective cesarean section. It is acknowledged that both diseases have their own peculiarities and specificities related to anesthesia and require careful consideration when it comes to selecting it. Bearing in mind the advantages and disadvantages of certain types of anesthesia, we believe that in this case, general anesthesia was a better choice compared to the regional techniques of anesthesia.Napretkom medicine u dijagnostici i liječenju određenih genetskih poremećaja sve više žena postiže reproduktivnu dob i željenu plodnost. Očuvanje trudnoće kao i njen završetak predstavlja pravi izazov ne samo za opstetričare, nego i za anesteziologe uključene u skrb takvih bolesnica. U našem slučaju prikazujemo anestezijski postupak za elektivni carski rez kod trudnice koja boluje od mišićne distrofije tipa 2 i suspektne von Willebrandove bolesti. Poznato je da obje bolesti imaju svoje osobitosti i specifičnosti vezane uz anesteziju te zahtijevaju pažljivo razmatranje oko odabira iste. Razmatrajući prednosti i nedostatke određene vrste anestezije smatramo da je u ovom slučaju opća anestezija bolji izbor u odnosu na regionalne tehnike izvođenja anestezije

EPIDURAL ANESTHESIA FOR CESAREAN SECTION IN A PATIENT WITH BRAIN ARTERIOVENOUS MALFORMATION – A CASE REPORT

Cilj nam je bio pokazati da se carski rez može uspješno izvesti u epiduralnoj anesteziji kod trudnice s arteriovenskom malformacijom (AV M). Intrakranijalne arteriovenske malformacije rijetko se viđaju u trudnoći. Završetak trudnoće carskim rezom izazov je za anesteziologa koji se skrbi za takve trudnice. Važno je razumjeti hemodinamske promjene koje se događaju u trudnoći i moždanu fiziologiju kao preduvjete za uspješno izvođenje anestezioloških postupaka i izbjegavanje mogućih komplikacija. Radi se o prikazu tridesetdvogodišnje trudnice s arteriovenskom malformacijom V. stupnja prema Spetzler-Martinovoj klasifikaciji. Primljena je u bolnicu zbog pogoršanja neurološkog statusa s ataksijom kao glavnim simptomom. Uzimajući u obzir njezin neurološki status i progresiju opstetričkog nalaza, odlučili smo završiti trudnoću carskim rezom u epiduralnoj anesteziji. Literaturni podaci o anesteziološkom zbrinjavanju trudnice s intrakranijalnom arteriovenskom malformacijom malobrojni su i kontradiktorni. Uspoređujući opću i spinalnu anesteziju s epiduralnom, smatrali smo da je epiduralna anestezija u ovom slučaju bolji izbor. Hemodinamska i respiratorna stabilnost majke i djeteta bile su održane tijekom operacije i u postpartalnom periodu. Nije bilo znakova pogoršanja majčina neurološkog statusa. Držimo da se carski rez kod trudnice s arteriovenskom malformacijom može sigurno izvesti u epiduralnoj anesteziji.Our goal was to demonstrate that cesarean section in a pregnant woman with arteriovenous malformation (AV M) can be successfully performed under epidural anesthesia. Intracranial arteriovenous malformations are rarely encountered in pregnancy. Completion of pregnancy by cesarean section imposes a great challenge for anesthesiologist taking care of these parturients. It is essential to understand hemodynamical changes during pregnancy and cerebral physiology in order to optimise anesthetic management and avoid possible complications. We report a case of a 32-year- -old pregnant woman with arteriovenous malformation grade V according to Spetzler Martin classification. She was admitted to hospital due to deterioration in her neurological status with ataxia as the leading symptom. Considering her neurological status and progression of obstetrical finding it was decided to complete the pregnancy by cesarean section under epidural anesthesia. The literature data about anesthetic management of parturients with intracranial AV M undergoing cesarean section are scarce and conflicting. In comparison with general and spinal anesthesia epidural anesthesia was considered as a better choice in this case. Hemodynamic and respiratory stability of mother and infant was maintained throughout the operation and in postpartal period. There were no signs of deterioration in maternal neurological status. Cesarean section in a woman with AV M grade V can be safely performed under epidural anesthesia

UTJECAJ PREPARTALNE AKUPUNKTURE (PPAC) NA POROĐAJ

Delivery is a natural process associated with a certain level of pain. With today’s range of various pain relieving methods during labor, it is possible to shorten laboring, thus ensuring better compliance of parturient woman. Prepartal acupuncture is one of these methods. The results of this prospective study showed that prepartal acupuncture had a positive infl uence on pain experience of parturient women. There was no difference in duration of the fi rst stage of labor between comparable groups, even in the primipara group. This study found acupuncture to have a positive infl uence on psychological state of the parturient women and general compliance during labor. Acupuncture should be considered as one of the possible methods for pain relief in labor and preparation for labor.Porođaj je prirodni proces povezan s određenom jačinom boli. Uz današnji raspon raznih metoda za ublažavanje boli moguće je porođaj i vremenski skratiti te time osigurati bolju suradnju rodilje. Prepartalna priprema akupunkturom jedna je od takvih metoda. Rezultati ovoga prospektivnog istraživanja pokazali su da prepartalna priprema akupunkturom djeluje pozitivno na rodilje u smislu subjektivno manjeg osjećaja boli, no nismo uspjeli potvrditi da skraćuje prvu porođajnu dob. U skupini rodilja koje su bile na prepartalnoj pripremi akupunkturom 7/26 rodilja je porođaj smatralo laganim za razliku od skupine rodilja koje nisu prošle prepartalnu pripremu akupunkturom, gdje je samo 1/25 rodilja porođaj smatrala laganim. Analizom trajanja prve porođajne dobi nije bilo statistički značajne razlike među skupinama (trajanje prve porođajne dobi kraće od 4 sata imalo je 14/25 žena u kontrolnoj skupini, a samo 4/13 žena u akupunkturnoj skupini). Između skupina nije bilo ni statistički značajne razlike u trajanju prve porođajne dobi ni kada su se uzele u obzir samo prvorotkinje (trajanje prve porođajne dobi kraće od 4 sata imalo je 6/13 žena u kontrolnoj skupini i samo 4/16 žena u akupunkturnoj skupini). Ovo istraživanje ukazuje na pozitivan utjecaj prepartalne pripreme akupunkturom na psihičku stabilnost rodilje i dobru suradljivost te na važnost podizanja svijesti o akupunkturi kao mogućnosti jedne od metoda pripreme za porođaj

The Efficacy of Dural Puncture Epidural Performed by 27-gauge Whitacre Needle in Labour Epidural Analgesia: Randomized Single-Blinded Controlled Study

Objective:Dural puncture epidural technique is refinement of standard epidural technique. Its goal is to overcome drawbacks of standard epidural. We assessed whether dural puncture epidural technique performed by 27-gauge spinal needle would provide higher quality of labour epidural analgesia by using 10 mL epidural bolus of 0.125% bupivacaine. Additionally, the impact of dural puncture epidural on epidural analgesia onset, course of labour and occurrence of maternal side effects was examined.Methods:We designed prospective, randomized, single-blind study. A total of 76 healthy nulliparous parturients were randomly allocated to dural puncture or standard epidural group. After identification of epidural space, spinal Whitacre needle was used for dural puncture. Intrathecal drug administration was omitted at that point. Both groups received a bolus of local anaesthetic mixture, followed by a continuous infusion of diluted local anaesthetic via epidural catheter. Pain was assessed by numeric pain rating scale. The number of top-ups and mode of delivery were recorded in both groups.Results:After 10 minutes, there was a statistically significant difference in numeric pain rating scale ≤3 reported (P=0.028), with 97.4% subjects in dural puncture epidural group achieving adequate analgesia after 10 minutes. There was no statistically significant difference in the number of additional boluses, time to delivery, Bromage scale achieved or maternal outcomes between groups.Conclusion:Dural puncture epidural technique appears to be effective in providing faster onset of epidural analgesia. However, the need for additional boluses remains unchanged. It can be safely used in obstetrics, without deleterious effect on the course of labour

Epiduralna analgezija u porodništvu - proturječja

Labor pain is one of the most severe pains. Labor is a complex and individual process with varying maternal requesting analgesia. Labor analgesia must be safe and accompanied by minimal amount of unwanted consequences for both the mother and the child, as well as for the delivery procedure. Epidural analgesia is the treatment that best meets these demands. According to the American Congress of Obstetrics and Gynecology and American Society of Anesthesiologists, mother’s demand is a reason enough for the introduction of epidural analgesia in labor, providing that no contraindications exist. The application of analgesics should not cease at the end of the second stage of labor, but it is recommended that lower concentration analgesics be then applied. Based on the latest studies, it can be claimed that epidural analgesia can be applied during the major part of the first and second stage of labor. According to previous investigations, there is no definitive conclusion about the incidence of instrumental delivery, duration of second stage of labor, time of epidural analgesia initiation, and long term outcomes for the newborn. Cooperation of obstetric and anesthesiology personnel, as well as appropriate technical equipment significantly decrease the need of instrumental completion of a delivery, as well as other complications encountered in the application of epidural analgesia. Our hospital offers 24/7 epidural analgesia service. The majority of pregnant women in our hospital were aware of the advantages of epidural analgesia for labor, however, only a small proportion of them used it, mainly because of inadequate level of information.Bol kod porođaja smatra se jednom od najjačih boli. Porođaj je složen i individualan proces s različitim željama žena za analgezijom. Analgezija u porođaju mora biti sigurna i s minimalnim neželjenim posljedicama za majku, dijete i za tijek porođaja. Tim uvjetima najbolje udovoljava epiduralna analgezija (EA). Prema American College of Obstetrics and Gynecology i American Society of Anesthesiologists za primjenu EA u porođaju dovoljna je želja rodilje ako ne postoji kontraindikacija. Davanje analgetika ne treba prestati na kraju drugog porođajnog doba, ali se tada preporučuju niske koncentracije lokalnog anestetika te dodavanje adjuvansa. Novije studije ukazuju na to da se EA može primijeniti u najvećem dijelu prvog i drugog porođajnog doba. Bez obzira na dosadašnja iskustva i istraživanja ne postoji slaganje oko učestalosti instrumentalnog dovršenja porođaja, trajanja drugog porođajnog doba uz EA i vremena uvođenja EA te dugoročnog utjecaja na dijete. Dobra suradnja opstetričkog i anesteziološkog osoblja i dobra tehnička opremljenost znatno smanjuju potrebu za instrumentalnim dovršenjem porođaja, kao i druge komplikacije EA. Naša bolnica nudi EA za olakšani porođaj tijekom 24 sata. Većina trudnica je svjesna prednosti primjene EA za vaginalni porođaj, međutim, samo mali broj trudnica iskoristi tu mogućnost, uglavnom zbog nedovoljne obaviještenosti o toj metodi

Trend and development of epidural analgesia and epidural anesthesia in the maternitiy ward of UHC Sestre milosrdnice over the past ten years

Tijekom posljednjih godina epiduralna analgezija za obezboljavanje vaginalnog porođaja primjenjuje se sve češće i jedna je od najčešće rabljenih regionalnih tehnika. Epiduralna anestezija uglavnom se rabi za hitni carski rez u rodilja koje već imaju postavljen epiduralni kateter za epiduralnu analgeziju tijekom vaginalnog porođaja. U rodilištu Kliničkoga bolničkog centra Sestre milosrdnice proveli smo retrospektivnu kohortnu studiju od 2008. do 2018. godine. Proučavali smo desetogodišnji trend incidencije epiduralne analgezije u odnosu prema ukupnom broju porođaja i incidencije epiduralne anestezije za hitni carski rez u odnosu prema ukupnom broju hitnih carskih rezova. U 2008. godini učestalost epiduralne analgezije u odnosu prema ukupnom broju porođaja bila je 21% (662/3125), a u 2018. godini 34% (1059/3083). U 2008. godini broj epiduralnih anestezija u odnosu prema ukupnom broju anestezija za hitni carski rez bio je 9% (51/552), a u 2018. 27% (172/639). Trend porasta vidljiv je kod obaju postupaka i iznosi 13% za epiduralne analgezije i 18% pri epiduralnim anestezijama.Over the years, epidural analgesia for pain relief of vaginal delivery is increasingly being applied and is one of the most frequently used regional techniques. Epidural anesthesia is mainly used in emergency cesarean section in parturients who already have an epidural catheter for epidural analgesia during vaginal delivery. In the delivery ward at the Sestre milosrdnice University Hospital Center we have conducted a retrospective cohort study from 2008 to 2018.We studied the incidence of epidural analgesia in relation to the total number of births and the incidence of epidural anesthesia for emergency cesarean section in relation to the total number of emergency cesarean sections. In 2008, the incidence of epidural analgesia in the relation to the total number of births was 21% (662/3125),and in 2018 it was 34% (1059/3083). In 2008, the number of epidural anesthesia for emergency cesarean section in the relation to the total number of emergency cesarean sections was 9% (51/552), andn in 2018 it was 27% (172/639). An increasing trend is seen in both procedures and is 13% for epidural analgesiaand 18% for epidural anesthesia

UTJECAJ PREPARTALNE AKUPUNKTURE (PPAC) NA POROĐAJ

Delivery is a natural process associated with a certain level of pain. With today’s range of various pain relieving methods during labor, it is possible to shorten laboring, thus ensuring better compliance of parturient woman. Prepartal acupuncture is one of these methods. The results of this prospective study showed that prepartal acupuncture had a positive infl uence on pain experience of parturient women. There was no difference in duration of the fi rst stage of labor between comparable groups, even in the primipara group. This study found acupuncture to have a positive infl uence on psychological state of the parturient women and general compliance during labor. Acupuncture should be considered as one of the possible methods for pain relief in labor and preparation for labor.Porođaj je prirodni proces povezan s određenom jačinom boli. Uz današnji raspon raznih metoda za ublažavanje boli moguće je porođaj i vremenski skratiti te time osigurati bolju suradnju rodilje. Prepartalna priprema akupunkturom jedna je od takvih metoda. Rezultati ovoga prospektivnog istraživanja pokazali su da prepartalna priprema akupunkturom djeluje pozitivno na rodilje u smislu subjektivno manjeg osjećaja boli, no nismo uspjeli potvrditi da skraćuje prvu porođajnu dob. U skupini rodilja koje su bile na prepartalnoj pripremi akupunkturom 7/26 rodilja je porođaj smatralo laganim za razliku od skupine rodilja koje nisu prošle prepartalnu pripremu akupunkturom, gdje je samo 1/25 rodilja porođaj smatrala laganim. Analizom trajanja prve porođajne dobi nije bilo statistički značajne razlike među skupinama (trajanje prve porođajne dobi kraće od 4 sata imalo je 14/25 žena u kontrolnoj skupini, a samo 4/13 žena u akupunkturnoj skupini). Između skupina nije bilo ni statistički značajne razlike u trajanju prve porođajne dobi ni kada su se uzele u obzir samo prvorotkinje (trajanje prve porođajne dobi kraće od 4 sata imalo je 6/13 žena u kontrolnoj skupini i samo 4/16 žena u akupunkturnoj skupini). Ovo istraživanje ukazuje na pozitivan utjecaj prepartalne pripreme akupunkturom na psihičku stabilnost rodilje i dobru suradljivost te na važnost podizanja svijesti o akupunkturi kao mogućnosti jedne od metoda pripreme za porođaj

Oxidative Stress Reduction by Midazolam Premedication during Oocyte Retrieval Procedure: Pilot Study

Infertility is one of the major medical problems nowadays. Couples who opt for In Vitro Fertilization (IVF) face a great deal of stress which certainly affects the outcome of the procedure. Therefore, we aimed to reduce the stress during the oocyte retrieval procedure by applying midazolam. Total oxidant (TOC) and antioxidant (TAC) capacities of serum, as well as glutathione (GSH) content and catalase activity, were measured in both control and midazolam groups. Follicular fluid was also tested for oxidant capacity and IL1β. Results implied that the midazolam group increased TAC at the end of the procedure. At the same time, the control group decreased GSH at the beginning of the procedure, and both groups decreased catalase activity at the end of the procedure. The results imply that stress during the procedure affects oxidative and antioxidative parameters of the patients, but did not affect the frequency of the pregnancy at the end of this pilot study. Yet, the results imply that oxidative and antioxidative mechanisms during IVF should be investigated in detail as they could affect the outcome of IVF