A perioperatív medicina szülészeti aspektusai

Napjainkban a világon a leggyakrabban végzett sebészi beavatkozás a császármetszés. Alapvető feltétel, hogy a műtétet szövődménymentesen lehessen végezni és a gyermekágyasok gyors posztoperatív felépülése biztosítható legyen, hiszen az anya–újszülött kapcsolatot már a műtét napján lehetővé kell tenni. A császármetszések mortalitása az elmúlt évtizedekben lényegesen csökkent, ez jelentős teammunka eredménye, valamint köszönhető a széles körben elterjedt gerincközeli érzéstelenítő eljárásoknak. A perinatológusteam tagja a szülészen és a neonatológuson kívül az aneszteziológus is, aki a páciens perioperatív ellátásáért felel. A szövődmények megelőzésének és korai eredményes kezelésének a feltétele, hogy az aneszteziológus már a terhesség során ismerkedjék meg a várandós nő állapotával, hogy megtervezhesse a perioperatív ellátást. A szerzők ismertetik a nagy kockázatú szülőnők csoportjait, a leggyakoribb anyai halálokokat és a preventív, valamint terápiás lehetőségeket. Orv. Hetil., 2014, 155(29), 1147–1151. | Recently the most frequently applied surgical procedure worldwide has been Cesarean section. It is essential to perform the operation without any complication. In addition, a fast postoperative recovery must be provided, because all mothers must have the chance for being together with their newborn infant even on the first day. The maternal mortality rates of Cesarean section significantly decreased in the last decades due to the planned team work as well as the widely applied regional (spinal and epidural) anesthetic procedures. Apart from the obstetrician and neonatologist the anesthesiologist is the member of the perinatal team, too, who is responsible for the patient’s perioperative care. To prevent complications and have an early successful treatment the anesthesiologist should be informed by the pregnant woman’ s health status in time in order to be able to plan the perioperative management. The high-risk groups of pregnant women, the most common causes of maternal death and possibilities of prevention and treatment are discussed. Orv. Hetil., 2014, 155(29), 1147–1151

مقايسه اثر هيدروکسی اتيل استارچ با کريستالوئيدها بر تغييرات هموديناميک

مقدمه: بسياری از مطالعات اثر مايعات کولوئيدی به عنوان يک جايگزين برای کريستالوئيد در کاهش بروز افت فشار خون در بي­حسی نخاعی را نشان داده­اند. اين مطالعه به منظور مقايسه اثر سه رژيم مايعات داخل وريدی بر تغييرات هموديناميک زير بي­حسی نخاعی در سزارين انجام شد. رژيم­ها شامل هيدرو ک سي­اتيل­استارچ 6 % به عنوان يک کولوئيد و دو کريستالوئيد نرمال سالی ن و رينگر لاکتات بودند. روش بررسی: در يک کارآزمايی بالينی دوسوکور ، 90 خانم باردار سالم نامزد سزارين انتخابی به صورت تصادفی يکی از سه رژيم مايعات رينگر لاکتات (1000 ميلي­ليتر) ، نرمال سالی ن (1000 ميلي­ليتر) و يا هيدروکسی اتيل استارچ (5/7 ميلي­ليتر به ازای هر کيلوگرم) را قبل از بي­حسی نخاعی را دريافت ک ردند . پارامترهای هموديناميک از جمله فشار خون و ضربان قلب ، pH خون بند ناف و آپگار نوزادان در سه گروه مقايسه شد. يافته­ها: تفاوت در اندازه­گيري­های اوليه هموديناميک در سه گروه وجود نداشت. افت فشار خون و مقدار مورد نياز از افدرين در گروه هيدرو ک سي­اتيل­استارچ کمتر بود.(008/0= p ) تفاوت معنی ­ داری در ناف pH خون بند ناف و يا نمره آپگار در گروه مداخله وجود نداشت. نتيجه­گيری: مايع درمانی با هيدرو ک سي­اتيل­استارچ موثر تر از کريستالوئيد در پيشگيری از افت فشار خون است اما در نمره آپگار و pH خون بند ناف موثرتر تفاوتی با کريستالوئيدها ندارد

Comparative study to evaluate the effect of colloid coloading versus crystalloid coloading for prevention of spinal anaesthesia induced hypotension and effect on fetal Apgar score in patients undergoing elective lower segment caesarean section: a prospective observational study

Background: Spinal anesthesia for LSCS has a high incidence of maternal hypotension which can be severe and disastrous for the fetus and the mother. Coloading in these patients is a physiologically more appropriate method for preventing spinal anesthesia induced hypotension.Methods: 100 ASA I patients for elective LSCS were randomly divided into two equal groups to either receive 1000ml colloid (6% Hetastarch) or 1000ml crystalloids (Ringer lactate) as coload. NIBP, heart rate SPO2 and incidence of nausea and vomiting and use of ephedrine to treat any hypotension was recorded. Fetal outcome was measured using APGAR score at 0, 1 and 5 minutes.Results: The incidence of hypotension was lesser with colloid coload group (41.7%) as compared to the crystalloid coload group (58.3%) but the difference between the two groups was statistically insignificant. Similarly, no statistically significant difference was noted in the incidence of nausea and vomiting and Fetal APGAR score between the two groups.Conclusions: Both Colloid and Crystalloid coloading is effective in decreasing the incidence of spinal anesthesia induced hypotension during LSCS with lesser incidence of hypotension and nausea vomiting with colloid coloading

Buckling loads for stiffened panels subjected to combined longitudinal compression and shear loadings: Results obtained with PASCO, EAL, and STAGS computer

The shear buckling analyses used in PASCO are summarized. The PASCO analyses include the basic VIPASA analysis, which is essentially exact for longitudinal and transverse loads, and a smeared orthotropic solution which was added to alleviate a shortcoming in the VIPASA analysis. Buckling results are presented for six stiffened panels loaded by combinations of longitudinal compression and shear. The buckling results were obtained with the PASCO, EAL, and STAGS computer programs. The EAL and STAGS solutions were obtained with a fine finite element mesh and provide calculations for the entire range of combinations of longitudinal compression and shear loadings

Resuscitation speed affects brain injury in a large animal model of traumatic brain injury and shock

Background: Optimal fluid resuscitation strategy following combined traumatic brain injury (TBI) and hemorrhagic shock (HS) remain controversial and the effect of resuscitation infusion speed on outcome is not well known. We have previously reported that bolus infusion of fresh frozen plasma (FFP) protects the brain compared with bolus infusion of 0.9% normal saline (NS). We now hypothesize reducing resuscitation infusion speed through a stepwise infusion speed increment protocol using either FFP or NS would provide neuroprotection compared with a high speed resuscitation protocol. Methods: 23 Yorkshire swine underwent a protocol of computer controlled TBI and 40% hemorrhage. Animals were left in shock (mean arterial pressure of 35 mmHg) for two hours prior to resuscitation with bolus FFP (n = 5, 50 ml/min) or stepwise infusion speed increment FFP (n = 6), bolus NS (n = 5, 165 ml/min) or stepwise infusion speed increment NS (n = 7). Hemodynamic variables over a 6-hour observation phase were recorded. Following euthanasia, brains were harvested and lesion size as well as brain swelling was measured. Results: Bolus FFP resuscitation resulted in greater brain swelling (22.36 ± 1.03% vs. 15.58 ± 2.52%, p = 0.04), but similar lesion size compared with stepwise resuscitation. This was associated with a lower cardiac output (CO: 4.81 ± 1.50 l/min vs. 5.45 ± 1.14 l/min, p = 0.03). In the NS groups, bolus infusion resulted in both increased brain swelling (37.24 ± 1.63% vs. 26.74 ± 1.33%, p = 0.05) as well as lesion size (3285.44 ± 130.81 mm3 vs. 2509.41 ± 297.44 mm3, p = 0.04). This was also associated with decreased cardiac output (NS: 4.37 ± 0.12 l/min vs. 6.35 ± 0.10 l/min, p < 0.01). Conclusions: In this clinically relevant model of combined TBI and HS, stepwise resuscitation protected the brain compared with bolus resuscitation

Comparison of preload versus coload by crystalloid in parturients undergoing caesarean section under spinal anaesthesia: an analytical study

Background: Spinal anesthesia is popular, simple and well accepted reliable technique for below umbilicus surgery. It is frequently used for lower segment section because of its rapid onset, a dense neural block, avoidance of risk of airway, little risk of local anesthetic toxicity and minimal transfer of drug to the fetus, as well as little risk of failure of block. Objectives of this study was to compare incidence and severity of hypotension, dose requirement of mephentermine and maternal bradycardia, shivering, nausea, vomiting. Methods: ASA grade I, II parturients posted for elective cesarean section were randomly allocated in two study groups of 55 each to receive either preload or co-load with Ringers lactate solution, blood pressure, heart rate, mephentermine requirement and other outcomes recorded at regular interval. Results: Hypotension was observed significantly less in co-loading group (37.18%) than preloading group (61.81%). Mean vasopressor requirement was also significantly more in preload group. Heart rate change, nausea, vomiting and fetal outcome remained same across both the groups. Conclusions: Co-loading with crystalloids is more effective strategy than preloading in prevention of spinal induced hypotension. We can save valuable time given for preloading in case of emergency caesarean sections

Literature Review: Fluid Therapy in Preventing Hypotension in Section Caesarean with Spinal Anesthesia

Background: Hypotension is a complication that often occurs in section Caesarea with spinal anesthesia. Severe hypotension poses serious risks to the mother (such as loss of consciousness) and the baby (such as oxygen deprivation and brain damage). So to prevent hypotension, it can be done by giving crystalloid or colloid fluid therapy after spinal anesthesia is carried out. Methods: Articles were searched using 3 databases (PubMed, Pro-Quest, and Google scholar) with a randomized controlled trial research method. The literature is limited between 2010 and 2019. Results: Seven articles with average results on administration of both preloaded and concomitant crystalline and colloidal fluids can reduce the incidence of hypotension, but for this technique Hypotension cannot be completely reduced and should be used with Vasopresor. Discussion and conclusion: The incidence of hypotension after spinal anesthesia should be treated immediately to prevent injury to the kidneys, heart, and brain by giving oxygen and increasing the rate of infusion (colored) of 100 ml of colloid or crystalloid fluid within the first 5 minutes or less for improving blood pressure. If blood pressure is still low after fluids are given, a vasoconstrictor such as ephedrine 5-10 mg can be gradually given

Colloid Versus Crystalloid Administration to Blunt the Sympathectomy of Neuraxial Anesthesia

Abstract: Background: The use of neuraxial anesthesia has allowed surgeons to facilitate numerous surgical procedures without the use of general anesthesia. While limiting the complications associated with a general anesthetic, the risk of complications remains prevalent due to the associated sympathectomy seen in neuraxial anesthesia use. The hemodynamic compromise seen in neuraxial anesthesia has significant implications for parturients as well as elderly patients with minimal reserves. While current practice continues to insist that crystalloid fluids should be administered to blunt the hypotension seen in neuraxial use, recent evidence suggests colloids fluids are much more efficacious. Method: After completing a literature review, an educational module was created to assess the knowledge of CRNAs practicing with neuraxial anesthesia use regularly, regarding the efficacy of colloid over crystalloid fluid usage in the population receiving such interventions. An educational module was presented, as well as a pretest and posttest questionnaire to understand the current knowledge base of anesthesia providers regarding the usage of colloid fluid administration in patients receiving neuraxial anesthesia. Results: A total of 8 survey respondents completed the pre-test and post-test. A total of 10 questions were asked to assess the knowledge of the CRNA regarding the usage of colloid fluid in neuraxial anesthesia. Of the 10 questions asked, CRNAs answered 3 more questions correctly on average after presentation of the educational module compared to the provided answers on the pretest analysis. After the presentation of the educational module, the greatest change in provided answers included the shift of providers stating they would be willing to utilize colloids in the presence of neuraxial anesthesia. Submitted answers shifted from 3 total responders claiming they would be likely or somewhat likely to use them, to 6 responders claiming they will be likely to utilize these products. Discussion: Along with an inherent increase in knowledge regarding the physiology and side effect profile seen in colloid fluid usage, the receptiveness of the surveyed providers to change upon the presentation of recent data is encouraging for healthcare. The increase in surveyed responders claiming their willingness to utilize colloid fluids in the presence of neuraxial anesthesia administration indicates the lack of hemodynamic stability and the association of implied risks seen in the current practice of crystalloid fluid administration. As previously discussed, limitations of the educational module include the inability for responders to truly note the associated costs involved in utilizing colloid over crystalloid fluid usage. Keywords: Sympathectomy, Colloid fluids, neuraxial anesthesia, hemodynamic stability, crystalloid fluids, vasopressor administration