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urgent c section anesthesia choice

urgent c section anesthesia choice

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Cesareo urg Cesareo urg Presentation Transcript

  • Cesareo urgente Quale Anestesia? Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Deterioramento fetale (Goodman J, Godewen J, Chance G eds. Fetal acid‑base physiology and fetal asphyxia. In Perinatal Medicine, Baltimore,Williams and Wilkins, 1977, p. 201) Cessazione di GC fetale adeguata (p.es FHR< 90,prolasso del cordone) ogni min pH 0.03-0.04 u. pCO2 3-4 mmHg BE interst 0.80. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Il significato di emergenza Diverso fra: anestesista ostetrico nurse paziente pediatra avvocato……o magistrato…………. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Sequenza temporale I 2-5 min spesi dall’anestesista non corrisponderebbero forse… alla modificazione della situazione ostetrica determinata da una più precoce decisione di operare…. Al miglioramento della condizione materno-fetale: » dec lat » ossigenazione » espansione volemia » tocolisi Anestesia e Rianimazione Ospedale di Faenza(RA) Servizio di
  • Conclusioni dai dati di mortalità-morbilità Non sarà che la mortalità -morbilità materna(e fetale) è più legata all’emergenza-urgenza che all’elezione? Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Indicazioni per C/S urgente Materne: » peggioramento acuto di malattia preesistente » emorragia massiva » trauma » arresto cardiaco(TC perimortem) Fetali: » parte fetale prolassata: – cordone, – estremità(fallita estraz podalica,fallita estraz di testa con distocia di spalla…) » compromissione della circolazione centrale: – deceleraz tardive non riflesse,senza variabilità, – bradicardia prolungata – acidemia fetale.. » Danno fetale – da trauma uterino,chiuso o penetrante – emorragia indotta dalla cordocentesi Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • intubazione tracheale difficile (da Rocke DA, Murray WB, Rout CC, Gouwns E: Relative risk analysis of factors associated with difficult intubation in Obstetric anesthesia. Anesthesiology 1992; 77:67‑73.) Caratteristica anatomica » Mallampati 4 » mandibola recedente » protrusione incisivi mascellari » Mallampati 3 » Collo corto » Mallampati 2 » Mallampati 1 Rischio relativo » 11.30 » 9.71 » 8.00 » 7.58 » 5.01 » 3.23 » 1.00 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Opinion on Anesthesia for emergency deliveries The entire obstetric care team should be alert to the parturient at increase risk from complications from emergency general or regional anesthesia. When risk factors are identified, an anesthesiologist should be consulted in the antepartum period to allow for joint development of a plan of management. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Valutazione preanestetica Vie aeree IOT funzionalità cardiovascolare precarico? funzionalità respiratoria allergie stratificazione del rischio Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Definito il rischio: Raduna aiuto prepara carrello intubazione difficile procedi alla analgesia in travaglio(pd cont) segui il parto visita regolare dell’area travaglio e del reparto di ostetricia; (Morgan BM, Magni V, Goroszeniuk T: Anaesthesia for emergency caesarean section. Br J Obstet Gynecol 1990;97:420 & Morgan M: Anaesthetic contribution to maternal mortality. Br J Anaesth 1987;59:842.) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Instaurazione precoce della analgesia(P.d.) in travaglio In generale, eviterà la GA. Permette la precoce scoperta di un catetere pd “sospetto”,che non sarà in grado di offrire analgesia chirurgica al bisogno…….. non tutte le anest reg sono in grado di portare a termine il parto operativo; » distress non anticipato intraop(dolore,emorragia massiva intraop Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Criteri di scelta dell’anestesia Regionale » Generale » laringoscopia precarico RV – risposta pressoria CO(shock?) – tempo di » riflesso FC(mal apnea..ipossiemia cardiache) – broncospasmo » risposta ai » agenti anestetici: vasopressori…. – Depress CV all’induz » Puntura – Succi ;K+ durale;PDPH – miorilass e mal .NM » brusca ICP(mal SNC) » vent spont nelle mal Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Listato dei punti di interesse Profilassi ab ingestis Posizionamento Vena di calibro adeguato Monitoraggio Preossigenazione Induzione Manovra di Sellick IOT Mantenim :preparto Mantenim post parto estubaz Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Topics Indications Contraindications Side effects Transplacentar passage: » effects on the fetus and neonate potentiating GA:reasons for:catecholamine reduction…… Crawford?? Obstetrical manoeuvers… Emergency CS Awareness avoidance—closed claims…. How:nearly all halogenated are equal…MAC properties Side effects Hypotension…but avoidance of aortocaval compression… Nausea & vomiting Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Indicazioni per GA in OBS Personale di anest con scarsa esperienza in reg Rifiuto della reg da parte della paz Paz non cooperante Tutti i casi di contrindicaz alla reg: » Infezlocalizzata(dorso) vs generalizzata (sepsis)…. » Coagulopatia: emergenza: distress fetale,placenta praevia, emorragia materna, manovre ostetriche urgenti ……. ipovolemia…. Certe cardiopatie che non possono tollerare ipotens:CO fisso,per es,stenosi aortica severa,Eisenmenger Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Parekh N,Husaini SWU,Russell IFCaesarean section for placenta praevia:a retrospective study of anesthetic management.Br.J.Anaesth. 2000;84:723-30. All anesth from 1 genn 1984 to 31/12/1998. 350 cases of plac previa: » 60% Reg / 40% AG » plc accreta;7 cases; 4 REG , 3 AG:but 2 reg convert.to AG…5 hysterect. » PA control during haemorrhage not a problem » Ra assoc.with less blood loss » “This retropectuve study do not support the often quoted motto that plac.praevia calls for AG….”. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Disadvantages of GA Asleep & unaware(late maternal bonding…) husband less likely to be allowed in OR drug depression of fetus stress response to intubation increased postoperative morbidity cardiovascular changes of intubation danger of aspiration(intubation & extubation) difficult intubation Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Ga:technique:I Premed;antacids/H2 blockers/sodium citrate LUD ID/ UI-D intervals as short as possible preoxygenation (precurarization) induction cricoid pressure Succi Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Ga:technique:II IOT check lung expansion,bilat. N20 50% + halog 0.6 Mac after delivery:repeat hypnotic + analgesic;stop volatile Oxytocin 10-20 UI/lt,drip… extubate awake and cooperative,having ascertained the full return of nm function… plan for failed intubation Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Indications for halogenated anesthetics potentiating GA:reasons for:catecholamine reduction…… Crawford?? Reduction or avoidance of maternal awareness,patient asleep and unaware optimum operating conditions Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Side effects Haemodynamics derangement uterine atonia… Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Halogenated agents:advantages.. allow use of increased O2 concentrations may increase uterine blood flow by decreasing maternal catecholamine mediated uterine artery constriction prevents awareness…but a few minutes are needed before the attainment of a reasonable MAC…(sevorane or desflurane more rapid equilibration! Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Halogenated agents:diasdvantages.. Uterine bleeding low apgar scores? Low neuroehavioral examinations theatre pollution... Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Modifications that affect inhalation anesthesia in pregnancy pain and discomfort thresholds MAC requirements 25%‑40%. FRC Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Transfer time Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Mac and pregnancy Mac for inhalational agents decresed by pregnancy(Datta et al,Chronically administered progesterone decreases halothane requirements in rabbits.Anesth.Analg. 1989;68:46-50) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Chan et al. Minimum Alveolar Concentration of Halothane and Enflurane Are Decreased in Early Pregnancy Anesthesiology 85:782-6, 1996 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • MAC reduction in pregnancy Gin T, Chan MTV: Decreased minimum alveolar concentration of isoflurane in pregnant humans. ANESTHESIOLOGY 81:829-32, 1994 ;& Chan et al. Minimum Alveolar Concentration of Halothane and Enflurane Are Decreased in Early Pregnancy Anesthesiology 85:782-6, 1996 1,8 1,6 1,4 1,2 1 0,8 isoflurane halothane enflurane 0,6 0,4 0,2 0 non pregnant pregnant Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Avoid maternal hyperventilation Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • King H, Ashley S, Brathwaite D, Decayette J, Wooten D: Adequacy of general anesthesia for cesarean section. Anesth Analg 77:84-8, 1993 68-130 sec 3min 2min inc 1 min ind skin inc Lifescan finger flexion hand squeeze lacrimation lryngoscopy,IOT 120 100 80 % of 60 patients 40 20 0 Isolated arm technique delivery 220-367 sec. Tps/scc/iot/N2O 50/haloth 0.5% Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Characteristics of inhaled anesthetics agent mw MAC Boling point Vapor press. Blood/gas partition coeff. pungency Soda lime desflu 168 rane N2O 44 6 23.5 663 0,42 yes stable 105 -88 no stable sevofl urane isoflur ane enflur ane haloth 200 2.0 58.5 39000 0,47 gas 160 0,60 no decomposes 184,5 1.15 48.5 238 1.4 184,5 1,68 56.5 175 1,9 197,4 0,75 50,2 241 2,4 moder Stable ate moder Stable ate none Decomposes Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Rise in alveolar(Fa) anesthetic concentration toward the inspired(Fi) concentration Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Navarro EM.Desflurane general anesthesia for cesarean section compared with isoflurane and epidural anesthesia.Anesthesiol.Intensivmed.Notfallmed.Schmerzther 2000;35;232-6. Desflurane 2.5% vs isofl 0.5% vs epid 15 ml ropi 0.75% + fent 100 microgr N2O 50% intraop haemodynamics blood loss maternal awareness Apgar scores 1-5 min NACS 2-24 h Ega UV/MV Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Navarro II No diff among the 3 groups except a more rapid emergence following des. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Olthoff D,Rohrbach A. Sevoflurane in obstetric anesthesia.Anesthesist 1998;47,suppl 1,s 63-9 Sevo > isofl and no outcome diff with epid, sevo> isof in pEEG monitoring……... Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Transplacentar passage Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Attenuation of catecholamine responses…….. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Shnider et al: Uterine blood flow and plasma norepinephrine changes during maternal stress in the pregnant ewe. ANESTHESIOLOGY 50:524-7, 1979 Electrically induced stress 30-60 sec, loud noises,sudden movement of personnel... 60 40 20 % change from basal 0 -20 1 2 3 4 5 -40 -60 -80 min Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) MAP Norepi uter.Blood flow
  • Uterine blood flow changes during anesth.in the pregnant ewe(from Shnider,Levinson,etc..) 20 15 10 5 % change from 0 control -5 -10 -15 -20 N2O 50% N2O 50% +haloth 0.5% N2O 50% + enfl 1% anest without stim anest with stimulation Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Maternal awareness of surgery and birth after barbiturate-relaxant induction &... 20 18 16 14 12 % 10 8 6 4 2 0 N2O 50% N2O 67-75% N2O 25-40%+halo 0.4% N2O 50%+haloth 0.3% N2O 50%+enfl 0,75 N2O 33%+metx 0.1% maternal awareness N2O 50+ isof 0,75% Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Lyons G, Macdonald R: Awareness during caesarean section. Anaesthesia 46:62-4, 1991 1982-1989 > 3000 patients questioned about recall and dreaming after general anaesthesia for Caesarean section 28 (0.9%) patients were able to recall something of their operation 189 (6.1%) reported dreams. Recollections of surgery were confined to manipulations, noises and voices. None of our patients complained of pain at the time of Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Incidence of awareness(from various sources) 16 14 12 10 C/S card.surg non card. Surg major trauma % 8 6 4 2 0 0.4 incidence Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Domino K, Posner KL, Caplan, R,Cheney F. Awareness during Anesthesia : A Closed Claims Analysis.Anesthesiology 90:1053-61, 1999. Liability risk Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Closed claim database for intraoperative awareness 79 over 4183 claims;1.9% : » 18 claims for awake paralysis(inadvertent paralysis of an awake patient » 61 claims for recall during GA :recall of events while receiving general anesthesia Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Awareness claims 1.9% of all claims awareness, defined as being paralyzed while awake or awake while receiving a general anesthetic, were reviewed. These claims were further divided into two categories: awake paralysis, i.e., the inadvertent paralysis of an awake patient, and recall during general anesthesia, i.e., patient recalled events while receiving general anesthesia. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Closed claim database for intraoperative awareness The majority of awareness claims involved : » » » » women (77%)(OR 3.21) younger than 60 yr of age (89%) ASA I—II (68%) who underwent elective surgery (87%),obs/gynecol. Claims for recall during general anesthesia were more likely to involve : » women (odds ratio [OR] = 3.08, 95% confidence interval [CI] = 1.58, 6.06) anesthetic techniques using intraoperative opioids (OR = 2.12, 95% CI = 1.20, 3.74) intraoperative muscle relaxants (OR = 2.28, 95% CI = 1.22, 4.25) and no volatile anesthetic (OR = 3.20, 95% CI = 1.88, 5.46). Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Dwyer R, Bennett HL, Eger EI II, Peterson N: Isoflurane anesthesia prevents unconscious learning. Anesth Analg 75:107-12, 1992 Several authors report prevention of conscious recall of events by relatively small concentrations of volatile anesthetics. Isoflurane in concentrations of 0.6 MAC prevented conscious recall and unconscious learning of factual information and behavioral suggestions. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Ranta S, Laurila R,Saario J,Ali-Melkkilä T, Hynynen M. Awareness with Recall During General Anesthesia: Incidence and Risk Factors Anesth Analg 1998; 86:1084 4818 operations under GA: 2612 (54%) patients were interviewed 10 (0.4% of those interviewed) patients were found to have undisputed awareness 9 (0.3%) patients with possible awareness. The doses of isoflurane (P < 0.01) and propofol (P < 0.05) were smaller in patients with awareness. 5 patients with awareness underwent a psychiatric evaluation;possible associtation with depression. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Moir, D. D .ANAESTHESIA FOR CAESAREAN SECTION An Evaluation of a Method using Low Concentrations of Halothane and 50 per cent of Oxygen Br. J. Anaesth. 1998; 80:690-696 The addition of 0.5 per cent of halothane vapour to a basic thiopentone, nitrous oxide, muscle relaxant anaesthetic technique does not increase blood loss at Caesarean section, does not affect the incidence of hypotension, and is likely to ensure unconsciousness. By permitting the administration of 50 per cent of oxygen with nitrous oxide, the condition of the newborn infant is likely to be improved. The use of 0.8 per cent of halothane vapour does not increase blood loss but is associated with a high incidence of Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Elective C/S:Duration of GA or Epidural antepartum and % of Apgar scores between 7-10 100 90 80 70 60 % 7-10 50 Apgar scores 40 30 20 10 0 (da dati di Robin,Shnider,Levinson---) Min: <5 6;10 11;20 21;30 31;60 GA epid Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • I-D & UI-D But more importantly than overall duration between induction and delivery (I-D) is the uterine incision-delivery interval(UI- D),that has been shown to correlate with fetal hypoxia and acidosis Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • GA and neonatal depression 100 90 80 70 60 50 40 30 20 10 0 spinal epidural GA Apgar 1' Apgar 5' Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Fetal-neonatal effects of halogenated vapours ONG BY,Cohen MM,Palahniuk RJ:Anesthesia for cesarean section: effects on neonates.Anesth.Analg 1989;68:270-275. Greater requirements for neonatal intubation and resuscitation versus regional block in urgent C/S Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Ong BY,Cohen MM,Palahniuk RJ.Anesthesia for cesarean section:effects on neonates.AA 1989;68:270-5. 3940 C/S;12.5% of neonates Apgar < 4 1.5% 5 min Apgar score < 4 list of factors associated with low 1 min Apgar scores: primiparity grand multiparity antepartum disease(preeclampsia,diabetes mellitus,maternal heart disease RH isoimmunization, early amtepartum haemorrhage) presence of fetal distress low gestational age use of narcotics during labor breech presentation nonelective C/S Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Ong et al.Anesthesia for cesarean section:effects on neonates.AA 1989;68:270-5. Multivariate analysis that controlled for many variables gave: Higher risk of low apgar at 1 min GA 3 >reg(2.5-3.88) Higher risk of low Apgar at 5 min; GA 3> reg(1.81-7) need for resuscitation: GA 2> reg(1.322.90) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Neonatal outcome after C/S by anesthetic technique:infants with 1 min Apgar score < 4 (%) Ong BY,Cohen MM,Palahniuk RJ.Anesthesia for cesarean section:effects on neonates.AA 1989;68:270-5. 0.01 45 40 35 30 elective 0.001 25 fetal distress failure to progress 20 15 10 0.05 5 0 reg GA Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Infants with 5 min Apgar score 0-4(%) Ong BY,Cohen MM,Palahniuk RJ.Anesthesia for cesarean section:effects on neonates.AA 1989;68:270-5. 0.01 9 8 7 6 5 0.01 4 3 2 elective fetal distress failure to progress 1 0 reg GA Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Neonates requiring oxygen by mask(%) Ong BY,Cohen MM,Palahniuk RJ.Anesthesia for cesarean section:effects on neonates.AA 1989;68:270-5. 0.001 25 20 0.01 15 elective fetal distress failure to progress 10 5 0 reg GA Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Neonates requiring iot and IPPV(%) Ong BY,Cohen MM,Palahniuk RJ.Anesthesia for cesarean section:effects on neonates.AA 1989;68:270-5. 0.001 45,0 40,0 35,0 30,0 elective fetal distress failure to progress 25,0 20,0 15,0 10,0 5,0 0,0 reg GA Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Gregory FA, Wagde JG, Biehl DR, Ong BY, Sitar DS. Foetal anaesthetic requirements (MAC) for halothane. Anesth Analg 1983;62:9 ‑ 14. Bachman CR, Biehl DR, Sitar DS, Cumming M, Pucci W. Isoflurane potency and cardiovascular effects during short exposures in the foetal lamb. Can Anaesth Soc J 1986;33:41‑ 7. MAC is significantly lower in fetal lambs than in lambs more than 24 hours of age. These findings suggest that neonates immediately after birth may be quite sensitive to inhalation anesthetics so that those exposed to general anesthetic agents may be less vigorous at birth. After assisted respirations and expiration of the anesthetic agents, these infants appear to resemble other infants, Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Neonatal deaths Ong BY,Cohen MM,Palahniuk RJ.Anesthesia for cesarean section:effects on neonates.AA 1989;68:270-5. 7 6 5 4 elective fetal distress failure to progress 3 2 1 0 reg GA Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Postpartum blood loss:Piggott SE,Bogod DG,Rosen M,Rees GAD,Harmer M.Isoflurane with either 100% oxygen or 50% nitrous oxide in oxygen for caesarean section.BJA 1990;65:32529. 0,0 -5,0 HB decrease, % -10,0 -15,0 elective emergent 0% + 1,2% 0% + ur 1,7 00%+ loth ,75 -25,0 2O aloth .5 -20,0 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Influence of anesthesia on blood loss at C/S(Moir DD.Anesthesia for cesarean section:an evaluation of a method using low concentrations of halothane and 50% of oxygen.BJA 1970;42:136-142. 800 700 600 500 N2O 70 N2O50+ aloth 0,5 N2O 50+ haloth 0,8 epid analg ml 400 300 200 100 0 blood loss Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • HCT values before and after C/S:(from Thirion et al.Maternal blood loss associated with low dose alothane administration for caesarean section.Anesthesiology 1988;69:a693) 40 35 30 25 % Hct preop HCTday 1 Hct day 2 20 15 10 5 0 haloth predelivery aloth pre& post epidural Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Conclusions for halog agents and blood loss Dose related decrease in uterine contractility and tone but no increase in blood loss if used in low-moderate concentrations: haloth 0.1-0.8 enflurane 0,5-1,5 isoflurane 0,75 sevoflurane….. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • In every case,after delivery of the neonate…... Stop the volatile anesthetic continue N2O(increase to 60-65%) administer a IInd dose of hypnotic(TPS 100-150 mg;propofol 60-100 mg + a potent analgesic:fentanyl 100-150 microgr..… nmb if needed Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Wojtczak, Jacek A., MD, PhD The Hemodynamic Effects of Halothane and Isoflurane in Chick Embryo Anesth Analg 2000; 90:1331 The cardiovascular effects of volatile anesthetics in prenatal hearts are not well investigated. The purpose of this study was to determine whether the embryonic cardiovascular system is sensitive to an exposure to clinically relevant, equipotent concentrations of halothane and isoflurane. Stage 24 (4-day-old) chick embryos were exposed to 0.09 and 0.16 mM of halothane and 0.17 and 0.29 mM of isoflurane. Dorsal aortic blood velocity was measured with a pulsedDoppler velocity meter. Halothane, but not isoflurane, caused a significant decrease in cardiac stroke volume and Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Effect of halothane on stroke volume and acceleration of aortic blood in chick embryos Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Effect of isoflurane on stroke volume and acceleration of aortic blood in chick embryos Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Biehl DR, Tweed A, Cote J, et al. Effect of halothane on cardiac output and regional flow in the fetal lamb in utero. Anesth Analg 1983; 62:489-92 We studied the effect of halothane on the fetal cardiovascular system of six lambs in utero by measuring fetal heart rate and femoral arterial blood pressure and by injecting labeled microspheres during a control period and again after 60 and 90 min of halothane anesthesia administered to six pregnant ewes at an inspired concentration of 1.5%. There were no significant effects on maternal Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Biehl et al. Effect of halothane on cardiac output and regional flow in the fetal lamb in utero. Anesth Analg 1983; 62:489-92 Halothane 1.5% 30 20 10 % change from 0 control -10 MAP HR heart BF brain BF -20 -30 -40 * * 8 * 16 * 32 * 60 96 min Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Bachman CR, Biehl DR, Sitar D, et al. Isoflurane potency and cardiovascular effects during short exposure in foetal lamb. Can Anesth Soc J 1986; 33:41-7 Isoflurane is a relatively new volatile anaesthetic in clinical practice and increasing use for obstetrical patients might be expected. A previous study demonstrated that a 60-90 minute exposure of the foetus to isoflurane resulted in a significant fall in foetal cardiac output with development of foetal acidosis. To determine the cardiovascular effects Ospedale di Faenza(RA) Servizio di Anestesia e Rianimazioneof a shorter
  • Baum VC, Palmisano BW. The immature heart and anesthesia. Anesthesiology 1997; 87:1529-48 volatile anesthetics inhibit myocardial function by depressing systems in addition to ICa,L even in neonatal myocardium. Baum and Wetzel showed that halothane, in clinically relevant concentrations, reversibly inhibits Na+— Ca2+ exchange in neonatal ventricular myocytes. This provides an additional mechanism that may be responsible for the more pronounced depression by Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Baum VC, Palmisano BW. The immature heart and anesthesia. Anesthesiology 1997; 87:1529-48 Halothane and isoflurane prolong AV conduction time directly. Anesthesia and O2 Consumption and Metabolism In vitro, halothane and isoflurane increase coronary flow in a dose-related manner in infant rabbit and fetal lamb hearts. In the isolated heart preparation in which coronary perfusion pressure is Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Baum VC, Palmisano BW. The immature heart and anesthesia. Anesthesiology 1997; 87:152948 In the neonatal lamb undergoing hypoxic stress, neither halothane nor isoflurane alter redistribution of blood to vital organs, including the heart. In addition, myocardial blood flow in the neonatal lamb decreases significantly at 1 MAC isoflurane (from 250 to 88 ml×100 g-1×min-1), but in exact proportion to Rianimazione Ospedale myocardial the decrease in di Faenza(RA) Servizio di Anestesia e
  • Baum VC, Palmisano BW. The immature heart and anesthesia. Anesthesiology 1997; 87:152948 In neonatal rabbit hearts studied in vitro with 1.5% halothane, McAuliffe and Hickey found no change in steady-state levels of high- energy phosphates or intracellular pH, despite a 50% decrement in mechanical performance. Significant uncoupling of oxidative phosphorylation cannot account for halothane's depressant effect on systolic function in the Ospedale di Servizio di Anestesia e Rianimazione neonate.Faenza(RA)
  • Baum VC, Palmisano BW. The immature heart and anesthesia. Anesthesiology 1997; 87:152948 Anesthesia and Systolic Function The effects of the inhalational anesthetics in intact immature hearts have been evaluated in several studies. Although one study suggested that the apparent increase in hemodynamic depression in the young heart in human studies may be a result of differences in anesthetic uptake and distribution, other Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Baum VC, Palmisano BW. The immature heart and anesthesia. Anesthesiology 1997; 87:152948 Summary Immature hearts are more profoundly affected by many anesthetics than are adult hearts. Maturational changes in a variety of cellular and subcellular systems and influences of the autonomic nervous system may be responsible, but as yet, specific mechanisms remain to be elucidated. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Brett CM, Teitel DF, Heymann MA, Rudolph AM: The young lamb can increase cardiovascular performance during isoflurane anesthesia. ANESTHESIOLOGY 71:751-6, 1989 Cardiac output and myocardial blood flow decrease dramatically in a dosedependent pattern in the young lamb during isoflurane anesthesia. This raises important questions about the ability of the young lamb to increase myocardial performance if oxygen delivery were compromised by a decrease in oxygen content during anesthesia and surgery. To investigate the ability of the young Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Coagulation and anesthesia The Effect of Anesthetic Techniques on Blood Coagulability in Parturients as Measured by Thromboelastography Sharma, Shiv K., MD, FRCA; Philip, John, MD : Anesthetic techniques may affect blood coagulability and the subsequent incidence of thromboembolic events. The purpose of this study was to Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Interactions of volatile agents with: nifedipine;enhancement of haemodynamic side effects with aloth,enfl,iso(but non pregnant animals…)..(and Rosone et al..Hemodynamic responses to nifedipine in dogs anesthetized with halothane. Anesth.Analg 1983;62:903908.) nicardipine enhancement of uterine Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • “Progesterone Decreases the MAC of Desflurane in the Non Pregnant Ewe,” was presented by Thompson and collaborators, Ochsner Clinic, New Orleans. They noted that the minimum alveolar concentration for pregnant ewes and that for nonpregnant ewes treated with progesterone were similar. The minimum alveolar concentration of desflurane in untreated nonpregnant Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Inhalational anesthetics with a rapid equilibration between inspiratory and end tidal concentraions,i.e less soluble,should provide the correct answer….. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • the maternal and neonatal effects of hsalothane,enflurane and isoflurane for cesarean delivery.Anesth.Analg 1983;62:516-520. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Datta et al.Maternal and fetal catecholamines and uterine incision-delivery interval during elective cesarean section.Obstet.Gynecol 1990;75:600-603. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Neurobehavioral examination Results more depressed(albeit subtle) in neonates born from GA than reg…. (Shnider 238 pagg…) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Wallace DH et al.Randomized comparison of regional and general anesthesia for cesarean delivery in pregnancies complicated by severe preeclampsia.Obstet Gynecol 1995;86,193- Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Gin T, Chan MTV: Decreased minimum alveolar concentration of isoflurane in pregnant humans. ANESTHESIOLOGY 81:829-32, 1994 <AB - BACKGROUND: Minimum alveolar concentration (MAC) is decreased in pregnant animals, but this change has not been demonstrated in humans, probably because of ethical considerations. It is less problematic to determine MAC in pregnant women undergoing termination of pregnancy, however, and therefore we compared the MAC of e Rianimazione Ospedale di Faenza(RA) Servizio di Anestesia isoflurane in these women
  • Chan M,Mainland P, Gin T Minimum Alveolar Concentration of Halothane and Enflurane Are Decreased in Early Pregnancy Anesthesiology 85:782-6, 1996 The MAC of halothane and enflurane were compared in pregnant women undergoing elective termination of pregnancy and in nonpregnant women. Methods: We studied 16 pregnant women scheduled for termination of pregnancy at 8 to 13 weeks gestation and 16 nonpregnant patients undergoing laparoscopic sterilization. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Induzione AG Tps < 7 mg/kg metohexital 1 mg/kg ketamina 1-1.5 mg/kg etomidate 0.25-0.30 mg/kg midazolam 0.2-0.3 mg/kg propofol 2.5 mg/kg non hanno significativi effetti sul destino neonatale Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Protezione emodinamica dallo stress dell’IOT Oppioidi a breve azione: » alfentanil 10 g/kg » remifentanil ??? Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Mantenimento anestetico fino al parto Ag.anestetici inalatori MAC? Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Dopo il parto Anestesia/analgesia indifferente? A patto che non deprima la contrattilità uterina…….. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Chemioprofilassi dell’ab ingestis Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Monitoraggio Appropriato per ogni sala op.( di chirurgia addominale) disponibilità di infusori rapidi di liquidi caldi possibilità monitoraggio PA continua cruenta e PVC possibilità di CO continuo…. Continuazione del monitoraggio fetale durante induzione dell’anestesia e la Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Posizione della paziente Prevenire la compressione aorto-cavale seduta:+ facile per le obese laterale;meglio per le presentazioni podaliche con membrane rotte Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Ossigenazione(e awareness) FiO2 1:UV pO2> FiO2 0.50(Bogod et al.Br.J.Anaesth 1988;61:255-62 per AG .e Ramanathan Anesth Analg 1982;61:576-81. per analg p.d. se N2O 50% ,MAC 0.5 -0.7 se FiO2 1,MAC 1.2:quindi: » haloth 1.1 *5 min,poi 0.75 » enflur 2.5 * 5 min,poi 1.7 » isofl 1.8 * 5 min,poi 1.2 » sevor 2.2 * 5 min,poi 1.5 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine.Anesthesiology 1997;87:979. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • access.Anesthesiology 1997;86:1392. Sevo 8%;incoscienza in 30”;5 min dopo i.v. per paralisi e iot Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Benumof JL Critical hemoglobin saturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine.Anesthesiology 1997;87:979. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Bilancia dell’AG Anestesia materna Minima depressione neonatale Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Minimizzazione dell’anestesia materna(‘40-’60) “awareness” Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Senza danno per il neonato: Moir,DD.Anesthesia for caesarean section:an evaluation of a method using low concentration of halothane and 50% oxygen.Br.J.Anaesth.1970;43:13642. Halothane 0.5% Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • “Fetal distress” The term fetal distress is imprecise,non specific and has little positive predictive value(ACOG Committee Opinion: Anesthesia for emergency deliveries. Number 104. March 1992) definizione: » progressive fetal asphyxia that, if not corrected or circumvented will result in decompensation of the physiologic responses (primarily redistribution ofblood flow to preserve oxygenation of vital organs) and cause permanent and central nervous system damage and other damage or death.”(Parer JT, Livingston EG: What is fetal distress? Am J Obstet Gynecol 162:1421, 1990) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • parto cesareo di urgenzaemergenza – In the obstetric and anesthetic management of emergent abdominal deliveries, "the maternal as well as fetal status must be considered .. The risk of general anesthesia must be weighed against the benerit for those patients who have a greater potential for complications... Cesarean deliveries which are performed for non‑ reassuring FHR patterns do not necessarily preclude the use of regional anesthesia.”(ACOG Committee Opinion: Anesthesia for emergency deliveries. Number 104. March 1992) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Domande: Potete ottenere una spinale nel + breve tempo possibile? Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Siete sempre in grado di garantire una spinale rapida? S p in a le r a p id a Si B u p i s e m p lic e ok NO AG non ok p r o b le m i d i io t Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • AG per il distress fetale Ket> TPS nel modello sperimentale Levinson G, Shnider SM, Gildea E, deLorimier M: Maternal and foetal cardiovascular changes and during ketamine anesthesia in pregnant ewes. Br J Anaesth 45:1111,1973:Pickering BG, Palahniuk RJ, Cote J, et al: Cerebral vascular responses to ketamine and thiopentone during foetal acidosis. Can.Anaesth Soc J 29:463, 1982 ma…..evidenza clinica=,senza contare le CI alla ket(preeclampsia,cocaine abuse….) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • FiO2 – Piggott SE, Bogod DG, Rosen M, Rees GAD: Isoflurane with either 100% oxygen or 50% nitrous oxide in oxygen Mocesarean – section. Br J Anaesth 61:255, 1990 – 34 Bogod DG, Rosen M, Rees GAD: Maximum Fi02 during cesarean section. Bir J Anaesth 61:255,1988 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Inhalation anestesia for caesarean section :why? How? C.Melloni Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Changes in obstetric anesthesia(C/S) in USA(Hawkins et al,Obstetric anesthesia workforce survey-1992 versus 1981.Anesthesiology 1994;81:A1128) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Epid Spi GA 1981 1992 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Changes in obstetric anesthesia(C/S) in UK(Brown et al.Int J.Obstet.Anesth.1995;4:214) 100% 80% Epid Spi GA 60% 40% 20% 0% 1982 1987 1992 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Number of deaths during cesarean section Number of deaths during cesarean section USA 1979-1990(Hawkins et al.Anesthesiology 86;280:1997) 1979-1984 1985-1990 GA 33 32 REG 19 9 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Fatality rates during cesarean Fatality rates during cesarean section section per million of Ga or REG 1979-1984 1985-1990 G.A. 20 32.3 REG 8.6 1.9 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Report on Confidential enquiries into maternal deaths in England and Wales 1970-1996 Frequenza per milione di gravid.stimate 30 emb.polm ipertens 25 anest 20 15 10 5 0 19 73- 76- 79- 82- 85- 88- 91- 9470- 75 78 81 84 87 90 93 96 emb.fluido amnio aborto gravid.ectopica emorragia sepsi rottura utero altre cause dirett Entrata Faenza(RA) Servizio di Anestesia e Rianimazione Ospedale di in vigore della nuova classificazione
  • Tsen LC, Camann W (2000) Training in obstetric general anaesthesia: a vanishing art?Anaesthesia. 55:179-83 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • cardiovascular and metabolic effects of halothane in normoxic and hypoxic newborn lambs. ANESTHESIOLOGY 62:732-7, 1985 Oxygen consumption, cardiac output, and tissue oxygen delivery were measured in normoxic and hypoxic 1-3day-old lambs during the following six conditions: 1) (control) paralysis with pancuronium and controlled ventilation with room air; 2) paralysis, controlled ventilation and hypoxia (PaO2 = 30 +/- 3 mmHg, [SD]); 3) paralysis, controlled ventilation with room air and 0.5 MAC Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • Effects of halothane anesthesia 0.5 & 1 Mac in normoxic and hypoxic lambs (Cameron et al. The cardiovascular and metabolic effects of halothane in normoxic and hypoxic newborn lambs. normoxia 1 mac normoxia 0.5mac hypoxia 1 mac hypoxia 0.5mac 300 250 200 150 mean % 100 change from control 50 0 -50 -100 hypoxia ANESTHESIOLOGY 62:732-7, 1985) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) O2 cons CO HR MPAP PVR lactic acid Norepi Epi SVR