Anest gen nel cesareo

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general anesthesia for cesarean section

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Anest gen nel cesareo

  1. 1. 1)Mortalità materna 2)Anest generale nel cesareo urgente e non Claudio Melloni Direttore U.O.Anestesia e Rianimazione Ospedale di Faenza Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  2. 2. Allan C. Barnes, M.D., Professor of Obstetrics and Gynecology, Johns Hopkins University, circa 1965. The removal of a brain tumor in an elderly patient calls for a surgeon with two assistants, scrub nurse and two circulating nurses, and an anesthetist and an assistant. The patient's prognosis is about 18 months and the hospital investment is tremendous. In contrast, the birth of a new baby at 4:00 a.m. is more often attended by one physician, no scrub nurse, one circulating nurse and inadequate or haphazard anesthesia coverage. As a profession, we seem to be committed to the fallacy that to be interesting, one has to be an adult, fully developed, and preferably degenerating. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  3. 3. Ostetricia ad alto rischio:posto per la regionale….. Una buona scelta anestetica puo’ migliorare la situazione: » epid * PIH/preeclampsia Una cattiva scelta anestetica puo’ peggiorare la situazione: » GA & intubaz. Difficile:l’autostrada per il disastro…. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  4. 4. WHO Mortalità materna: 5-10/100.000 gravidanze paesi sviluppati 500-1000 /100.000 paesi sottosviluppati 500.000 morti materne per anno Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  5. 5. Betran et al National estimates for maternal mortality:an analysis based on WHO Systematic Review of maternal mortality ane morbidity .BMC Public Health 2005,5.131 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  6. 6. Dati WHO 1990 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  7. 7. Mortalità materna in Italia Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  8. 8. Mortalità materna in England e Wales 1847-1984 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  9. 9. «Underreporting » Francia 56% – Bouvier-Colle.J.Int.J.Epidemiol 1991 Olanda 26% – Schuitemaker Obstet.Gynecol 1997 Austria 38% – Karimian Acta Obstet Gynecol Scand 2002 Finlandia 60% – Gissler Acta Obstet Gynecol Scand 1997 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  10. 10. Ministero della Salute La mortalità materna è stata inclusa negli eventi sentinella per lo studio e la riduzione del rischio clinico Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  11. 11. CP.Anesthesia related deaths during obstetric delivery in the United States(Anesthesiology 1997;86:277-84). Morti materne in USA 1979-1990 cause Relazione con l’anestesia Tipo di procedura ostetrica Condizioni materne concomitanti Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  12. 12. Hawkins et al.Anesthesia related deaths during obstetric delivery in the United States(Anesthesiology 1997;86:277-84). num.tot=129 18 16 14 12 10 % 8 6 4 2 0 GA REG ignota sedazione 79-81 82-84 85-87 88-90 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  13. 13. CP.Anesthesia related deaths during obstetric delivery in the United States(Anesthesiology 1997;86:277-84). M o r t a lit à o s t e t r ic a C S 82% p a rto v a g 5 % ig n o to 1 3 % Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  14. 14. C/S Mortality (from Hawkins…) AG: 52% d el total e asp i r az 33% p rob l d i i n d u z/ i n t u b az 22% ven t i l a z i n ad eg 15% O ppioidi o sedativi paren t 3% i n su f resp 3% arrest o card d u ran t e an est 22% R egionale 25 % ep i d u r a l e 70% Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) sp i n al e 30%
  15. 15. 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)
  16. 16. 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)
  17. 17. Causes of anesthesia related deaths Causes of anesthesia related deaths USA 1979-1990(Hawkins et al.Anesthesiology 86;280:1997) AG(67) Reg(33) sedaz(4) ignota(25) % N Probl.vie aeree 73 - 75 40 49 62 arresto card.intraop 22 6 - 52 23 30 tox da AL 51 - - 13 17 spi/pd alta 36 - - 9 12 iperdosaggio - 25 - 1 1 anafilassi - - 4 1 1 5 6 - 4 5 6 100 100 100 100 129 ignota % 100 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  18. 18. Incidenza della mortalità materna da CDC USA: GA vs reg. GA 2.3 * > reg (1979—1984) GA 16.7 * > reg ( 1985—1990). Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  19. 19. Mortalità materna attribuita all’anestesia 4.3/milione di nati vivi( 1979—1981) 8.7/milione di nati vivi( 1979—1981) 1.7/ milione di nati vivi (1988—1990). CDC USA 1.7/ milione di nati vivi (1988—1990). CEMDEW Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  20. 20. Report on Confidential enquiries into maternal deaths in England and Wales 1970-1999 Frequenza per milione di gravid.stimate 35 emb.polm 30 ipertens 25 anest 20 emb.fluido amniotico 15 aborto gravid.ectopica 10 emorragia 5 0 sepsi 19 73- 76- 79- 82- 8570- 75 78 81 84 87 72 88- 9190 93 94- 9796 99 rottura utero altre cause dirette Entrata Faenza(RA) Servizio di Anestesia e Rianimazione Ospedale di in vigore della nuova classificazione
  21. 21. Mortalità ostetrica attribuita all’anestesia 1970-1999 CEMDUK 14 12 10 8 6 4 2 0 19 7072 7375 7678 7981 8284 8587 8890 9193 9496 9799 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  22. 22. Effetti ipotensivi dell’ossitocina Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  23. 23. Fatti salienti da CDC USA: la mortalità anestetica legata all’anestesia;cause e differenze fra AG e reg. Il numero assoluto di morti materne da AG è rimasto stabile negli anni 1979-1990. I problemi di vie aeree sono la causa principale di mortalità da AG,mentre il numero assoluto di morti legate alla anest.reg. è in calo dal 1984,equamente divise fra tossicità da AL e anestesia spinale/perid alta. Tuttavia sono diminuite le morti da tossicità da AL da quando Food and Drug Administration ha tolto l’approvazione per la bupivacaina 0.75% in ostetricia. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  24. 24. Complications of AG for C/S: CDC USA 20.0/milione GA ( 1979—1984) 32.3 morti/milione (1985—1990) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  25. 25. CS: mortalità per anest reg CDC USA 8.6 /milioni di anest reg ( 1979—1984) 1.9 /milione ( 1985—1990). Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  26. 26. Perché è possibile che ci sia ancora una mortalità + alta con AG? Perché negli ultimi anni non si fanno + AG!!! Paz + anziane Paz + ammalate Classi socioeconomiche meno abbienti….immigrati….. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  27. 27. Instaurazione precoce della analgesia(P.d.) in travaglio In generale, eviterà la GA. Permette la precoce scoperta di un catetere pd “sospetto”, …….. non tutte le anest reg sono in grado di portare a termine il parto operativo; » distress non anticipato intraop(dolore,emorragia massiva intraop con instabilità emodinamica….) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  28. 28. GA:pro & contro veloce Alta % successo Pieno controllo Rilasc.uterino (alog..) Meno ipotens Protez delle vie aeree (ma nel mentre….) Probl. Con vie aeree Aspirazione Ipertens durante laringoscopia e intubaz Depressione cardiaca Depressione resp Depressione neonatale “Awareness” Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  29. 29. Anestesia regionale;pro & contro cosciente Psicologico… Legame materno/fetale: la madre si fa carico immediatamente del neonato… No intubazione Minor rischio di inalaz Analgesia postop Soddisfazione materna Tecnicamente + difficile Consumo di tempo ipotensione Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  30. 30. Indicazioni per AG (QCCH,Crowhurst 2001) cord prolapse sev.fetal distress maternal request failed reg Reg contraindicated Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  31. 31. Richiesta materna per AG Ansietà Pregressa esperienza: cattiva(con reg) » buona(con GA) » dorsalgia » Quando non vengono visitate nella clinica preop o prenaest……. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  32. 32. Anesthesia for emergency C/S Morgan et al.BJA 1990;97:420-24 “need for emergency C/S anticipated in 87% (380 cases).Early establishment of epidural analgesia in labour allowed extension to adequate anaesthesia in 70%” Crowhurst(ESOA 2001);99% extension Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  33. 33. Domande sull’emergenza Epid in sede:quanto ci vuole dal rifornimento ad un blocco adeg.per C/S? Intervallo decisione-parto Rischio fetale:quanto da AG e quanto da reg? Strategie che beneficino il feto…….. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  34. 34. CESDI:Confidential Enquiry into Stillbirths and deaths in infancy,7th report,2000 Composizione: » OB anesthesia focus group » 2 ob anesthesiologists » 2 obstetricians 873 perinatal deaths;25(2,8%)anesth.contributing factors identified: » » » » » maternal anaphylaxis1, maternal bronchospasm and hypoxia 1, failed/difficult oti 2 Delay with personnel 11 Delay in administering anesth 10 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  35. 35. Ottimizzazione della fisiologia materno fertale 1)Materna: 1)trasporto di O2 » 2)ventilazione » 3)circolazione » 4)flusso ematico uteroplacentare 5)flusso ematico ombelicale(fetal) 1-4 possono essere ottimizzati Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  36. 36. 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)
  37. 37. Valutazione preanestetica Vie aeree IOT:anestesisti e ostetrici….. Gaiser RR, McGonigal ET, Litts P, et al: Obstetricians’ ability to assess the airway. Obstet Gynecol 1999; 93(5 Pt 1):648–652 funzionalità cardiovascolare funzionalità respiratoria allergie precarico? stratificazione del rischio Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  38. 38. Valutazione vie aeree:Mallampati,Cormack etc Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  39. 39. Test di protrusione mandibolare Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  40. 40. 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.) PREVENZIONE DELLE EMERGENZE NELL 87% DEI CASI Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  41. 41. Ricorso non necessario alla AG Inadeguata educazione della paziente abitudini chirurgiche chiamata tardiva controindicazioni sorpassate: » preeclampsia » placenta praevia » febbre » mal.cardiache Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  42. 42. Prevenzione delle C/S di urgenza(Morgan,Brit J Obstet Gynecol 1990;97:420) visite preop congiunte 3 volte al dì analgesia peridurale raccomandata per tutte le madri a rischio di C/S comunicazione continua fra reparto di ostetricia e anestesia …risoluzione dei problemi organizzativi…... Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  43. 43. 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 controindicaz alla reg: » Infez localizzata(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)
  44. 44. 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 retropective study do not support the often quoted motto that plac.praevia calls for AG….”. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  45. 45. Svantaggi della AG Paz addormentata e inconscia:legame materno neonatale più tardivo… Marito meno probabile sia presente in sala op Depressione fetale da farmaci Risposta da stress all’IOT Aum morbilità postop Modificaz cardiovasc all’intubaz Pericolo di inalazione (intubaz & estubaz…) Intubaz difficile Dati di mortalità;CEMDUK,USA,ecc. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  46. 46. AG:tecnica :I Premed;antiacidi /H2 bloccanti/citrato di sodio LUD: » Manuale,inclinazione del leto,cuneo sotto anca dx…. ID/ UI-D intervalli + brevi possibile preO2 (precurarizzazione)???? induzione “cricoid pressure” Succi odicuraro del giorno? Ospedale di Faenza(RA) Servizio Anestesia e Rianimazione
  47. 47. AG:tecnica:II IOT Controlla espansione polm,bilat. N20 50% + halog 0.6 Mac Dopo parto:ripeti ipnotico + analgesico;stop volatile Ossitocina 10-20 UI/lt,drip…:lentamente!!! Estubare solo se sveglia e cooperante,assicurandosi della piena ripresa nm … Pianificare per la fallita intubazione Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  48. 48. 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)
  49. 49. Posizione LUD;spostamento uterino a sn LLT;tilt laterale del letto a sn Trendelemburg lieve? » Implicazioni per rigurgito….. Posizione ottimale per IOT:”Sniffing position” “orecchie sopra le spalle” Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  50. 50. Monitoraggio Appropriato per ogni sala op. di chirurgia addominale: NIBP(ogni 1-2 min);ECG;SaO2,etCO2,TV,Paw,RR,N2O,alog….. 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 preparazione chirurgica dell’addome……. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  51. 51. Capnometria sidestream Ossigenazione e FiO2 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  52. 52. Ossigenazione / preossigenazione Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  53. 53. 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)
  54. 54. Tempo di apnea fino al raggiungimento di una SaO2 specifica in pazienti in AG con confronto tratto da un modello matematico Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  55. 55. Frequenza di iot fallite 16 anni di esperienza del St James 5802 GA per C/S 0.4% di iot fallite;1/300 1984,1/250 1994. » , L.; Hawthorne Wilson, R.; Lyons, G.; Dresner, M. Failed intubation revisited: 17-yr experience in a teaching maternity unit » Br. J. Anaesth. 1996; 76:680-684. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  56. 56. Frequenza di iot fallite(Tsen et al,Int J.Obset Anesth. 1998;7:147) 16 14 12 10 % 8 6 4 2 0 1990 1991 1992 1993 1994 1995 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) iot fallite
  57. 57. Cause delle iot difficili Variazioni anatomiche fattori organizzativi: » inesperienza » urgenze fuori orario » “stat” mentalità » panico Iot fallite e tipo di C/S(Hawthorn,BJA 1996 90 80 70 60 50 % 40 30 20 10 0 % AG fallite ele ttive e me rgenza Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  58. 58. Il Mallampati varia durante il travaglio!!! Farcon EL.,Kim MH,Marx GF. Changing Mallampati score during labour Canadian Journal of Anaesthesia. 41(1). 1994. 50-51. » Primigravuida sana » All’ingresso:Mallampati 1-2 » A 8 cm di dilatazione:Mallampati 3-4(edema dell’ipofaringe) » Immediato postpartum:Mall;3-4 » 1 H postpartum:Mall 1-2. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  59. 59. Aumento delle iot difficili in ostetricia 1.8 1.6 1.4 % 1.2 1 chir gen C/S (Pilk) C/S (Durban) ost (Carli) 0.8 0.6 0.4 0.2 0 score 3 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  60. 60. Cause delle iot difficili Variazioni anatomiche fattori organizzativi: » inesperienza » urgenze fuori orario » “stat” mentalità » panico Iot fallite e tipo di C/S(Hawthorn,BJA 1996 90 80 70 60 50 % 40 30 20 10 0 % AG fallite ele ttive e me rgenza Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  61. 61. Manovra di Sellick Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  62. 62. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  63. 63. of an effective cricoid pressure. Anaesthesia 1983; 38:461-466. 44 Newton= 4.5 kg Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  64. 64. Brimacombe JR,Berry AM.Cricoid pressure .Can J Anaesth 1997 ; 44: 414-425 Purpose: Although cricoid pressure (CP) is a superficially simple and appropriate mechanical method to protect the patient from regurgitation and gastric insufflation, in practice it is a complex manoeuvre which is difficult to perform optimally. The purpose of this review is to examine and evaluate studies on the application of (CP). It deals with anatomical and physiological considerations, techniques employed, safety and efficacy issues and the impact of CP on airway management with special mention of the laryngeal mask airway. Source of material: Three medical databases (48 Hours, Medline, and Reference Manager Update) were searched for citations containing key words, subject headings and text entries on CP to October 1996. Principle Findings: There have been no studies proving that CP is beneficial, yet there is evidence that it is often ineffective and that it may increase the risk of failed intubation and regurgitation. After evaluation of all available data, potential guidelines are suggested for optimal use of CP in routine and complex situations. Conclusions: If CP is to remain standard practice during induction of anaesthesia, it must be shown to be safe and effective. Meanwhile, further understanding of its advantages and limitations, improved training in its use, and guidelines on optimal force and method of application should lead to better patient care. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  65. 65. Evidenza a vantaggio della manovra di SELLICK Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  66. 66. Evidenza contraria alla manovra di SELLICK Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  67. 67. Gruppi di pazienti a rischio da una manovra di Sellick inappropriata Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  68. 68. Carrello per intubazione In sala op. laringoscopi:manico normale,sottile ,corto lame curve,rette,Bizzarri,ecc Guedel,Copa LMA di vari calibri mandrino di gomma,con ventilazione set crico tiroidotomia:Patil,Ravussin,ecc fibroscopio…….. jet ventilation……... Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  69. 69. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  70. 70. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  71. 71. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  72. 72. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  73. 73. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  74. 74. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  75. 75. Hawthorne L,Wilson, R.; Lyons, G.; Dresner, M. Failed intubation revisited: 17-yr experience in a teaching maternity unit .Br. J. Anaesth. 1996; 76:680-684 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  76. 76. Gataure PS,Hughes JA.The laryngeal mask airway in obstetrical anaesthesia.Report of Investigation. CAN J ANAESTH 1995 / 42: 2 / pp130-3 questionario sull’utilizzo della LMA in caso di difficile o fallita intubaz in ostetricia 240 consultant in anestesia UK 72% favorevoli 10% con esperienza personale 2,5% asseriscono che la LMA ha salvato la paziente Opinione generale che debba essere usata prima della cricotiroidotomia Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  77. 77. LMA in ostetricia 1. McClune S, Regan M, Moore J. Laryngeal mask airway for caesarean section. Anaesthesia 1990;45:227–8 2. de Mello WF, Kocan M. Further options for obstetric anaesthesia. Br J Hosp Med 1989;42:426. 3. Storey J. The laryngeal mask for failed intubation at caesarean section. Anaesth Intensive Care 1992;20:118–9 4. Christian AS, McClune S, Moore JA. Failed obstetric intubation. Anaesthesia 1990;45:995. 5. Chadwick LS, Vohra A. Anaesthesia for emergency Caesarean section using the Brain laryngeal mask airway. Anaesthesia 1989;44:261–2. 6. Lim W, Wareham C. The laryngeal mask in failed intubation. Anaesthesia 1990;41:689–90. 7. Priscu V, Priscu L, Soroker D. Laryngeal mask for failed intubation in emergency Caesarean section. Can J Anaesth 1992;39:893. 8. Hasham FM, Andrews PJD, Juneja MM, Ackermann III WE. The laryngeal mask airway facilitates intubation at cesarean section: a case report of difficult intubation. Int J Obstet Anesth 1993;2:181–2. 9. McFarlane C. Failed intubation in an obese obstetric patient and the laryngeal mask. Int J Obstet Anesth 1993;2:183–4. 10. Vanner RG. The laryngeal mask in the failed intubation drill. Int J Obstet Anesth 1995;4:191–2. 11. Brimacombe J. Emergency airway management in rural practice: use of the laryngeal mask airway. Australian J Rural Health 1995;3:10–9. 12. de Mello WF, Kocan M. The laryngeal mask in failed intubation. Anaesthesia 1990;41:689–90. 13. Godley M, Ramachandra AR. Use of LMA for awake intubation for Caesarean section. Can J Anaesth 1996;43:299– 302. 14. de Mello WF, Restall J. Difficult intubation. Can J Anaesth 1990;37:486. 15. Davies JM, Weeks S, Crone LA. Failed intubation at caesarean section. Anaesth Intensive Care 1991;19:303. 16. Shung J, Avidan MS, Ing R, et al. Awake intubation of the difficult airway with the intubating laryngeal mask airway. Anaesthesia 1998;53:645–9. 17. Hawthorne L, Wilson R, Lyons G, Dresner M. Failed intubation revisited: 17-yr experience in a teaching maternity unit. Br J Anaesth 1996;76:680–4. 18. Gataure PS, Hughes JA. The laryngeal mask airway in obstetrical anaesthesia. Can J Anaesth 1995;42:130–133. 19. White A, Sinclair M, Pillai R. Laryngeal mask airway for coronary artery bypass grafting. Anaesthesia 1991;46:234. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  78. 78. LMA Proseal Han TH, Brimacombe J, Lee EJ, Yang HS. The laryngeal mask airway is effective and probably safe in selected healthy parturients for elective Cesarean section. Can J Anaesth 2001;48:1117–21. Awan R, Nolan JP, Cook TM: Use of a ProSeal laryngeal mask airway for airway maintenance during emergency caesarean section after failed tracheal intubation. Br J Anaesth 2004; 92:144–146 Brown NI, Mack PF, Mitera DM, et al: Use of the ProSeal laryngeal mask airway in a pregnant patient with a difficult airway during electroconvulsive therapy. Br J Anaesth 2003; 91:752–754 Bullingham A: Use of the ProSeal laryngeal mask airway for airway maintenance during emergency caesarean section after failed intubation. Br J Anaesth 2004; 92:903 Keller C,Brimacombe J,Lirk P,Pühringer F.Failed Obstetric Tracheal Intubation and Postoperative Respiratory Support with the ProSeal™ Laryngeal Mask Airway ] Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  79. 79. Conclusioni sulla intubazione difficile Mettere a punto l’organizzazione;informazione,visite,educazione,Sell ick…... valutare le vie aeree adottare una pratica che sottolinei l’ossigenazione ed il risveglio della madre praticare regolarmente ! evitare l’AG. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  80. 80. Intubazione Adiuvanti: NMB: » Succi 1-1.5 mg/kg » Rocuronium 1.2 mg/kg(60”)-0.6 mg/kg(80”) – Abouleish E, Abboud T, Lechevalier T, Zhu J, Chalian A, Alford K. Rocuronium (Org 9426) for Caesarean section. British Journal of Anaesthesia 1994; 73:336-341. » Vecuronium 0.2 mg/kg » ??? » Atracurium peggio della DTC per il neonato Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  81. 81. Perreault C,Guay J,Gaudreault P,Cyrenne L,Varin F.Residual curarization in the neonate after cesarean section.Can J.Anesth 1991;39:587 – ABSTRACT: The transplacental transfer and the neonatal effects of atracurium 0.3 mg × kg-1 (ED95) were compared with those of d-tubocurarine at the usual clinical dose of 0.3 mg × kg-1 (ED90) in 46 patients undergoing elective Caesarean section. The atracurium group (25 patients) was similar to the d-tubocurarine group (21 patients) as far as age, parity and time intervals between precurarization, induction, skin incision, muscle relaxant administration, hysterotomy and birth. The transplacental transfer of atracurium was lower than that of d-tubocurarine, with a fetomaternal ratio of 9 ± 3% for atracurium and 12 ± 5% for d-tubocurarine (P < 0.05). The transplacental transfer of laudanosine was low at 14 ± 5%, with blood levels of 0.101 ± 0.032 mM × L-1 in the umbilical vein. Newborns in the two groups were comparable in terms of Apgar scores at one, five and ten minutes, as well as for NACS scores (neurological and adaptive capacity scoring test) at two and 24 hours after birth. However, at 15 min after birth, only 55% of newborns in whom the mothers received atracurium had a normal NACS score (³ 35/40) compared with 83% of newborns in whom the mothers received d-tubocurarine (P < 0.05). Further analysis of the five variables related to active muscle tone revealed that the modal score for active extension of the neck of newborns from the atracurium group was lower than for newborns from the d-tubocurarine group (P < 0.01). This was compatible with the effect of residual curarization among newborns in whom the mothers received atracurium. However, this effect was transient since there was no difference found between the two groups at two and 24 hr after birth. Furthermore, no newborn had clinical signs of respiratory distress. In conclusion, atracurium given at a dose of 0.3 mg × kg-1 for Caesarean section may lead to partial residual curarization of neonates 15 min after birth. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  82. 82. Fattori di rischio associati alla 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)
  83. 83. FiO2 – Piggott SE, Bogod DG, Rosen M, Rees GAD: Isoflurane with either 100% oxygen or 50% nitrous oxide in oxygen for cesarean 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)
  84. 84. Khaw, K S.; Wang C C, Kee W D. Ngan Pang C P, Rogers, M.S.Effects of high oxygen inspired fraction during electice caesarean section under spinal anesthesia on maternal and fetal oxygenation and lipid peroxidation.BJA 2002;88:18-23 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  85. 85. Ossigenazione O2 50% + N2O 50% vs O2 100%: » UvpO2 + alta di 6-7 torr;pH o BD no diff! – Bogod BJA 1988,PIGGOTT BJA 1989 » Se si aum FiO2,aumenta anche il vapore!!! » Aumentare la FiO2 nell’intervallo IU-D non porta aumenti nella ossigenazione fetale(poco tempo??) » Perreault, C., Blaise, G. A; Meloche, R.. » Maternal inspired oxygen concentration and fetal oxygenation during cesarean section.Can.Anesth.Soc.J.1992 ;39:155 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  86. 86. Kee WD Ngan, Khaw KS,Ma KC,Wong ASY, Lee B. Randomized double blind comparison of different oxygen inspired fractions during general anesthesia for cesarean section.BJA 2002;89:556. We randomized patients having elective Caesarean section to receive one of the following: FIO2 0.3, FIN2O 0.7 and end-tidal sevoflurane 0.6% (Group 30, n=20); FIO2, 0.5, FIN2O 0.5 and end-tidal sevoflurane 1.0% (Group 50, n=20), or FIO2 1.0 and end-tidal sevoflurane 2.0% (Group 100, n=20) until delivery. Neonatal outcome was compared biochemically and clinically. Results. At delivery, for umbilical venous blood, mean PO2 was greater in Group 100 (7.6 (SD 3.7) kPa) compared with both Group 30 (4.0 (1.1) kPa, P<0.0001) and Group 50 (4.7 (0.9) kPa, P=0.002) and oxygen content was greater in Group 100 (17.2 (1.6) ml dl-1) compared with both Group 30 (12.8 (3.6) ml dl-1, P=0.0001) and Group 50 (13.8 (2.6) ml dl-1, P=0.0001). For umbilical arterial blood, PO2 was greater in Group 100 (3.2 (0.4) kPa) compared with Group 30 (2.4 (0.7) kPa, P=0.003), and in Group 50 (2.9 (0.8) kPa) compared with Group 30 (2.4 (0.7) kPa, P=0.04); oxygen content was greater in Group 100 (10.8 (3.5) ml dl-1) than in Group 30 (7.0 (3.0) ml dl-1, P<0.01). Apgar scores, neonatal neurologic and adaptive capacity scores, and maternal arterial plasma concentrations of epinephrine and norepinephrine before induction and at delivery were similar among groups. No patient reported intraoperative awareness. Conclusions. Use of FIO2 1.0 during general anaesthesia for elective Caesarean section increased fetal oxygenation. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  87. 87. Kee WD Ngan, Khaw KS,Ma KC,Wong ASY, Lee B. Randomized double blind comparison of different oxygen inspired fractions during general anesthesia for cesarean section.BJA 2002;89:556. FiO2 FiN2O Sevoflurane % 0.30 0.70 0.6 0.50 0.50 1 1 0 2 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  88. 88. Kee WD Ngan, Khaw KS,Ma KC,Wong ASY, Lee B. Randomized double blind comparison of different oxygen inspired fractions during general anesthesia for cesarean section.BJA 2002;89:556. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  89. 89. 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)
  90. 90. Perreault, C., Blaise, G. A; Meloche, R. Maternal inspired oxygen concentration and fetal oxygenation during cesarean section.Can.Anesth.Soc.J.1992 ;39:155. » » This study was designed to determine whether fetal arterial and venous PO2 could be increased by increasing maternal FIO2 in the period between hysterotomy and birth. Two groups of ten patients were studied. All were anaesthetised with the same technique except for the FIO2 after hysterotomy. One group inspired 50% oxygen and the second group inspired 100% oxygen. Although the maternal arterial PO2 was higher at birth in the 100% O2 group (177.4 ± 42.3 mmHg vs 281.0 ± 94.2 mmHg), there were no differences between the arterial umbilical cord PO2 (19.3 ± 5.7 mmHg vs 18.5 ± 7.3 mmHg) and the venous umbilical cord PO2 (31.1 ± 7.6 mmHg vs 33.0 ± 10.8 mmHg). Awareness was present in one patient in the 50% O2 group and in four patients in the 100% O2 group but this difference was not statistically significant. It is concluded that a higher inspired maternal oxygen concentration between hysterotomy and birth does not result in any increase in fetal PO2. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  91. 91. Mantenimento AG Postpartum N2O/O2 66/33,70/30……. Alogenato????(atonia uterina!!!) Amnesia » (diazepam 5-10 mg,midazolam 2-5 mg) Analgesia:morfina 0.2-0.3 mg/kg,fentanile 2-3 microgr /kg Ripetere ipnotico Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  92. 92. Bilancia dell’AG Anestesia materna Minima depressione neonatale Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  93. 93. Indicazioni per gli anest.alogenati Potenziamento della AG:riduzione delle catecolamine materne…… Crawford?? Riduzione o eliminazione della sensazione di veglia materna:paziente addormentata e inconscia Condizioni operative ottimali Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  94. 94. Effetti collaterali Alterazioni emodinamiche Atonia uterina… Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  95. 95. Vantaggi degli alogenati Permettono alte FiO2 Possono aum il flusso ematico uterino diminuendo la vasocostrizione delle art uterine mediata dalle catecolamine materne Previene l’ awareness…ma sono necessari alcuni min prima di ottenere un MAC ragionevole (sevoflurane o desflurane equilibrano + rapidamente Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  96. 96. Svantaggi degli alogenati Sanguinam. uterino Bassi punteggi di Apgar? Bassi punteggi nelle valut.neurocomportamentali Inquinamento ambientale Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  97. 97. Modificazioni indotte dalla gravidanza che influenzano l’anest inalatoria Soglia per dolore e fastidio MAC richieste :25%‑40% » Datta et al,Chronically administered progesterone decreases halothane requirements in rabbits.Anesth.Analg. 1989;68:46-50) . FRC Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  98. 98. 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)
  99. 99. Riduzione MAC in gravidanza 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)
  100. 100. Gin T, Chan MTV: Decreased minimum alveolar concentration of isoflurane in pregnant humans. ANESTHESIOLOGY 81:829-32, 1994 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 isoflurane in these women with the MAC in matched nonpregnant women. METHODS: Patients underwent inhalational induction of anesthesia with isoflurane and tracheal intubation. MAC was determined in each patient by testing the response to a 10-s, 50-Hz, 80-mA transcutaneous tetanic electrical stimulus to the ulnar nerve at varying concentrations of isoflurane. The end-tidal concentration of isoflurane was kept constant for 10 min before each stimulus and the concentration of isoflurane ultimately varied in steps of 0.05% until we obtained a sequence of three alternate responses (move, not move, move) or (not move, move, not move). MAC for each patient was taken as the mean of the two concentrations just permitting and just preventing movement. MAC for the group was taken as the median of the individual MAC values. A blood sample was taken immediately before induction of anesthesia for measurement of progesterone concentrations. Data were compared between groups by the Mann-Whitney test. RESULTS: The median (range) MAC for isoflurane in the pregnant group, 0.775% (0.675-0.825), was less than that in the nonpregnant group, 1.075% (1.025-1.175) (P < 0.001). The median (range) plasma progesterone concentration in the pregnant group, 63.4 (0.8-106) nM, was greater than that in the nonpregnant group, 8.4 (0.7-66) nM (P < 0.02). CONCLUSIONS: The MAC of isoflurane Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  101. 101. 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. Eight patients in each group received halothane and the others received enflurane. After inhalational induction of anesthesia and tracheal intubation, MAC was determined in each patient by observing the motor response to a 10-s, 50-Hz, 80-mA transcutaneous electric tetanic stimulus to the ulnar nerve at varying concentrations of either halothane or enflurane. The end-tidal concentration of inhalational anesthetic was kept constant for at least 15 min before each stimulus and the concentration was varied ultimately in steps of 0.05 vol% (halothane) or 0.10 vol% (enflurane) until a sequence of three alternate responses (move, not move, move) or (not move, move, not move) was obtained. Minimum alveolar concentration for each person was taken as the mean of the two concentrations just permitting and just preventing movement, and MAC for the group was the median of individual MAC values. Confidence intervals were calculated for the percentage decrease in MAC for pregnant women compared with nonpregnant women. Results: The median (range) MAC of halothane, 0.58 vol% (0.53 to 0.58), and enflurane, 1.15 vol% (0.95—1.25), in the pregnant women were less than those in the nonpregnant women, 0.75 vol% (0.70 to 0.78), P = 0.0005 and 1.65 vol% (1.45 to 1.75), PFaenza(RA) Servizio di Anestesia e Rianimazione Ospedale di = 0.0007, respectively. The
  102. 102. Avoid maternal hyperventilation Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  103. 103. Conseguenze della iperventilazione materna (da Shnider,Moya,Levinson,Cosmi…) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  104. 104. 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)
  105. 105. Characteristics of inhaled anesthetics agent mw MAC Boling point Vapor press. Blood/gas partition coeff. pungency Soda lime desflur ane 168 6 23.5 663 0,42 yes stable N2O 44 105 -88 no stable sevoflu rane 200 2.0 58.5 39000 0,47 gas 160 0,60 no decomposes isoflura ne 184,5 1.15 48.5 238 moder Stable ate moder Stable ate none Decomposes 1.4 enflura 184,5 1,68 56.5 175 1,9 ne halotha 197,4 0,75 50,2 241 2,4 ne Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  106. 106. Rapidità della crescita della concentrazione alveolare (Fa)di anestetico in relazione alla concentrazione inspirata (Fi) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  107. 107. 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)
  108. 108. Navarro II No diff among the 3 groups except a more rapid emergence following des. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  109. 109. 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)
  110. 110. Attenuazione della risposta catecolaminica Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  111. 111. 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
  112. 112. Modificazioni del flusso ematico uterino durante anestesia nella scimmia gravida (from 20 15 10 5 % change from 0 control -5 -10 -15 -20 Shnider,Levinson,etc..) 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)
  113. 113. 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)
  114. 114. Lyons G, Macdonald R: Awareness during caesarean section. Anaesthesia 46:62-4, 1991 1982-1989 > 3000 patients questioned about recall and dreaming after GA for C/S 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 interview, although one since has. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  115. 115. Incidenza della 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)
  116. 116. Domino K, Posner KL, Caplan, R,Cheney F. Awareness during Anesthesia : A Closed Claims analysis.Anesthesiology 90:1053-61, 1999. Liability risk Rischio della responsabilità Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  117. 117. Dwyer R, Bennett HL, Eger EI II, Peterson N: Isoflurane anesthesia prevents unconscious learning. Anesth Analg 75:107-12, 1992 Parecchi autori riportano che la prevenzione del ricordo cosciente di eventi si ottiene con concentrazionei relativamente basse di anestetici volatili . Isoflurane 0.6 MAC previene il ricordo conscio e l’apprendimento incosciente di informazioni fattuali e i suggerimenti comportamentali Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  118. 118. 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 hypotension and for this reason is not advisable. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  119. 119. Eger, Edmond I, II,.Age, Minimum Alveolar Anesthetic Concentration, and Minimum Alveolar Anesthetic Concentration-Awake .Anesthesia & Analgesia 2001; 93:947953 MAC-Awake is also close to the anesthetic concentration suppressing memory and learning » Dwyer R, Bennett HL, Eger EI, Heilbron D. Effects of isoflurane and nitrous oxide in subanesthetic concentrations on memory and responsiveness in volunteers. Anesthesiology 1992; 77:888-98. » Dwyer R, Bennett HL, Eger EI, Peterson N. Isoflurane anesthesia prevents unconscious learning. Anesth Analg 1992; 75:107-12. » Chortkoff BS, Bennett HL, Eger EI. Subanesthetic concentrations of isoflurane suppress learning as defined by the category-example task. Anesthesiology 1993; 79:16-22. » Chortkoff BS, Gonsowski CT, Bennett HL. Subanesthetic concentrations of desflurane and propofol suppress recall of emotionally charged information. Anesth Analg 1995; 81:728-36. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  120. 120. MAC AWAKE End-tidal anaesthetic concentrations at first eye opening in response to a verbal command during recovery from anaesthesia MAC-Awake, the end-tidal anesthetic concentration at 1 atm that suppresses the appropriate response to command in 50% of subjects. Autori Rivista/anno MAC MAC awake GAUMANN Br. J. Anaesth. 1992; 68:81-4 Isof 1.2 0.30%=0.25 Mac Haloth 0.8 0.45%=0.50/0/59 mac Enflurane 1.7 0.45%=0.27 mac Sevo 0.61%=0.33 mac ISOf 0.39%=0.33 mac isof 0.41% KATOH Br. J. Anaesth. 1992; 69:259-62 Suzuki Anesth Analg 1998; 86:179–83 sevoflurane 0.7% Katoh Anesth Analg 1993; 76:348–52 sevo 0.62% Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  121. 121. Outcome dopo GA Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  122. 122. C/S elettivi:Durata della GA o Epidurale antepartum e % di Apgar tra 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)
  123. 123. I-D & UI-D Ma + importante che la durata totale fra induzione e parto (I-D) ,quello critico è L’ intervallo incis.uterina /parto (UI- D),che ha dimostrato correlazione con la ipossia fetale e l’acidosi Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  124. 124. GA e depressione del neonato 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)
  125. 125. Efetti fetali e neonatali degli alogenati Maggiore frequenza di resuscitazione neonatale dopo AG vs regionale » ONG BY,Cohen MM,Palahniuk RJ:Anesthesia for cesarean section: effects on neonates.Anesth.Analg 1989;68:270-275. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  126. 126. 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 Lista dei fattori associati con bassi punteggi di Apgar a 1 min » primiparià » grande multiparità » Patologie antepartum (preeclampsia,diabetes mellitus,mal cardiache materne, isoimmunizzazione RH , emorragia precoce amtepartum) » Presenza di fetal distress » Bassa età gestazionale » Uso di narcotici durante travaglio » Presentazione podalica » C/S non elettivo Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  127. 127. Ong et al.Anesthesia for cesarean section:effects on neonates.AA 1989;68:270-5. Una analisi multivariata che ha controllato per molte variabili ha dato : Rischio + alto per bassi valori di Apgar a 1 min GA 3 >reg(2.5-3.88) Rischio + alto per bassi valori di Apgar a 5 min; GA 3> reg(1.81-7) Necessità di resuscitazione : GA 2> reg(1.32-2.90) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  128. 128. Destino del neonato dopo C/S a seconda della tecnica anestetica:piccoli con 1 min Apgar < 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 25 0.001 20 15 10 0.05 5 0 elective fetal distress failure to progress reg GA Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  129. 129. Piccoli con 5 min Apgar 0-4(%) Ong BY,Cohen MM,Palahniuk RJ.Anesthesia for cesarean section:effects on neonates.AA 1989;68:270-5. 9 0.01 8 7 6 5 0.01 4 3 elective fetal distress failure to progress 2 1 0 reg GA Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  130. 130. Neonati che hanno necessitato O2 per maschera 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)
  131. 131. Neonati che hano richiesto iot e IPPV(%) Ong BY,Cohen MM,Palahniuk RJ.Anesthesia for cesarean section:effects on neonates.AA 1989;68:270-5. 45,0 0.001 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)
  132. 132. Morti neonatali 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)
  133. 133. 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 è significativamente più basso nei feti agnelli che nei neonati agnelli > 24 h di età. » Questi dati suggeriscono che i neonati subito dopo il parto possono essere particolarmente sensibili agli anest.inalatori ,per cui quelli esposti agli anest.generali possono essere meno vigorosi alla nascita .Dopo avere assistito la respirazione e l’espirazione degli anest inalati questi infanti sono simili agli altri Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  134. 134. La depressione della contrattilità uterina da alogenati sub Mac ripercussioni cliniche sulle perdite ematiche? Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  135. 135. 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 elective emergent -15.0 -20.0 -25.0 N2O 50+haloth 0.5 O2100%+ haloth 0,75 02 100% + enflur 1,7 02 100% + isofl 1,2% Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  136. 136. Influenza dell’anestesia sulle perdite ematiche nel 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)
  137. 137. HCT :valori prima e dopo 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)
  138. 138. Conclusioni sugli alogenati e le perdite ematiche Decremento nella contrattilità e tono uterino dose dipendente Ma nessun incremento nelle perdite ematiche se somministrati in concentrazioni basse/moderate: haloth 0.1-0.8 enflurane 0,5-1,5 isoflurane 0,75 Sevoflurane 0.8-1.5….. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  139. 139. In ogni caso;dopo il parto …... Stop l’anest volatile continua N2O(aum al 60-65%) Somministra una II dose di ipnotico (TPS 100-150 mg;propofol 60-100 mg + Un potente analgesico :fentanyl 100-150 microgr..… nmb se necessari…… Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  140. 140. Interazioni degli anest volatili con: Potenziamento dei miorilassanti nifedipina; » aum degli eff,coll. con aloth,enfl,isof( ma non su animali gravidi) – Rosone et al..Hemodynamic responses to nifedipine in dogs anesthetized with halothane. Anesth.Analg 1983;62:903-908.) Nicardipina: aum dell’atonia uterina ,non facilmente reversibile post partum con oxitocin: – Csapo et al.Deactivation of the uterus during normal and premature labor by the calcium antagonist nicardipine.Am,J.Obstet.Gynecol. 1982;142:483-91 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  141. 141. 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)
  142. 142. Ipnoinduttori e C/S Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  143. 143. Gin T,O'Meara ME,Kan AF,Leung RKW,Tan P,Yau G.PLASMA CATECHOLAMINES AND NEONATAL CONDITION AFTER INDUCTION OF ANAESTHESIA WITH PROPOFOL OR THIOPENTONE AT CAESAREAN SECTION Br. J. Anaesth. 1993; 70:311-6 C/S elettivi,feto singolo TPS 4 mg/kg vs propofol 2 mg/kg + succi/ iot dopo 1 min/ atrac/isof MAP TPS + 29 (SD 15) mm Hg propofol + 18 (14) mm Hg) Max noradr conc Max adr conc 413 (177) pg ml-1 ==== 333 (108) pg ml-1 === Apgar,NACS,catecol ombelicali,EGA,CO2 simili nei 2 gruppi Propofol attenua la risposta ipertensiva e catecolaminica all’iot;senza differenze di outcome Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  144. 144. Gin T,Yau G,Jong W,Tan P,Leung RKW,Chan K. DISPOSITION OF PROPOFOL AT CAESAREAN SECTION AND IN THE POSTPARTUM PERIOD CAN J ANAESTH 1991 / 38: 1 / 31-6 ABSTRACT: We have compared the pharmacokinetics of a bolus dose of propofol 2 mg kg-1 in eight patients undergoing Caesarean section with those in eight postpartum patients undergoing sterilization by mini-laparotomy. The Caesarean section group had a total body clearance of (median) 31.5 (range 24.4–53.3)ml min-1 kg-1, apparent volume of distribution at steady state 5.10 (2.46–6.61) litre kg-1 and mean residence time 161 (52.3–251)min; values for the postpartum group were 33.8 (21.5–47.2) ml min-1 kg-1, 5.17 (3.47–8.09) litre kg-1 and 163 (92.3–238) min, respectively. The 95% confidence interval for the umbilical venous to maternal venous ratio of propofol at delivery was 0.62–0.86. Plasma protein binding studies showed there was less unbound propofol in maternal plasma (1.28– 2.29%) compared with umbilical plasma (2.08–3.88%) (P < 0.01). Neonatal concentrations of propofol were greater than maternal concentrations at 2 h and were in the range 0.05–0.11 mg ml-1 at 4 h Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  145. 145. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  146. 146. Gin T,Yau G,Chan K,Gregory MA,Oh TE.Disposition of propofol infusions for Caesarean section.CAN J ANAESTH 1991 / 38: 1 / pp31-6 ABSTRACT: The disposition of propofol was studied in women undergoing elective Caesarean section. Indices of maternal recovery and neonatal assessment were correlated with venous concentrations of propofol. After induction of anaesthesia with propofol 2.0 mg × kg-1, ten patients received propofol 6 mg × kg-1 × hr-1 with nitrous oxide 50 per cent in oxygen (low group) and nine were given propofol 9 mg × kg-1 × hr-1 with oxygen 100 per cent (high group). Pharmacokinetic variables were similar between the groups. The mean ± SD Vss = 2.38 ± 1.16 L × kg-1, Cl = 39.2 ± 9.75 ml × min-1 × kg-1 and t1/2b = 126 ± 68.7 min. At the time of delivery (8–16 min), the concentration of propofol ranged from 1.91–3.82 mg × ml-1 in the maternal vein (MV), 1.00–2.00 mg × ml-1 in the umbilical vein (UV) and 0.53–1.66 mg × ml-1 in the umbilical artery (UA). Neonates with high UV concentrations of propofol at delivery had lower neurologic and adaptive capacity scores 15 minutes later. The concentrations of propofol were similar between groups during the infusion but they declined at a faster rate in the low group postoperatively. Maternal recovery times did not depend on the total dose of propofol but the concentration of propofol at the time of eye opening was greater in the high group than the low group (1.74 ± 0.51 vs 1.24 ± 0.32 mg × ml-1, P < 0.01). The rapid placental transfer of propofol during Caesarean section requires propofol infusions to be given cautiously, especially when induction to delivery times are long. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  147. 147. Gin T,Yau G,Chan K,Gregory MA,Oh TE.Disposition of propofol infusions for Caesarean section.CAN J ANAESTH 1991 / 38: 1 / pp31-6 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  148. 148. Gin T,Yau G,Chan K,Gregory MA,Oh TE.Disposition of propofol infusions for Caesarean section.CAN J ANAESTH 1991 / 38: 1 / pp31-6 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  149. 149. Gin T,Yau G,Chan K,Gregory MA,Oh TE.Disposition of propofol infusions for Caesarean section.CAN J ANAESTH 1991 / 38: 1 / pp31-6 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  150. 150. The mean UV/MV ratio of 0.52 is lower than the 0.65–0.85 seen after bolus induction doses of propofol and the 0.76 during an infusion study with I-D times of 7–31 min. Our I-D times (8–16 min) are shorter than the previous infusion study and the lower UV/MV would indicate there is still a gradient for placental transfer from the maternal to fetal circulations. The mean UA/UV ratio of 0.61 is similar to the 0.70 with previous infusions and 0.67 after bolus induction with short I-D times of 4–7 min. This indicates continuing fetal tissue uptake. However, bolus induction studies with longer I-D times have UA/UV ratios of 1.09 and 1.07 which imply more complete fetal distribution. Neonatal depression in the low-infusion group was similar to that found after an anaesthetic technique using thiopentone for induction of anaesthesia and nitrous oxide and enflurane for maintenance of anaesthesia. The negative correlation between NACS and UV concentrations of propofol provides some evidence of neonatal depression due to propofol. Although infusion times were too short to differentiate maternal concentrations of propofol between the two groups, a high-dose infusion combined with a long induction to delivery time is likely to produce high UV concentrations of propofol and low neonatal NACS scores. The neonatal elimination of propofol is slower than the maternal elimination (unpublished observations). Neonatal glucuronidation is poorly developed but sulphation activity is similar to that found in adults. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  151. 151. Kee WD Ngan,Khaw KS, Ma ML., RN,Mainland P-A, Gin T. Postoperative Analgesic Requirement After Cesarean Section: A Comparison of Anesthetic Induction with Ketamine or Thiopental. Anesth Analg 1997; 85:1294 ABSTRACT: In a randomized, double-blind study, we compared postoperative pain and analgesic requirement in patients who underwent elective cesarean section under general anesthesia induced with thiopental 4 mg/kg (n = 20) or ketamine 1 mg/kg (n = 20). Anesthesia was maintained with nitrous oxide and isoflurane. Postoperative analgesia was provided by patient-controlled analgesia (PCA) using morphine. Median (range) time to first PCA demand was greater in the ketamine group (28 [3–134] min) compared with the thiopental group (20.5 [3–60] min; P = 0.04). Median (range) morphine consumption over 24 h was less in the ketamine group (24.3 [3–41] mg) compared with the thiopental group (35 [4–67] mg; P = 0.017). Visual analog scale pain scores were similar between groups. No patients had recall of intraoperative events or unpleasant dreams. Two patients in the thiopental group and one patient in the ketamine group had pleasant intraoperative dreams. Apgar scores were similar between groups. Median umbilical venous pH was higher (7.33 vs 7.31; P = 0.04) and attributable to lower median umbilical venous PCO2 (5.72 vs 6.14 kPa; P = 0.02) in the ketamine group compared with the thiopental group. Induction of anesthesia for cesarean section using ketamine is associated with a lower postoperative analgesic requirement compared with thiopental. Implications: Patients who had anesthesia for cesarean section induced with ketamine required less analgesic drugs in the first 24 h compared with patients who received thiopental. Ketamine, unlike thiopental, has analgesic properties that may reduce sensitization of pain pathways and extend into the postoperative period. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  152. 152. Kee WD Ngan,Khaw KS, Ma ML., RN,Mainland P-A, Gin T. Postoperative Analgesic Requirement After Cesarean Section: A Comparison of Anesthetic Induction with Ketamine or Thiopental. Anesth Analg 1997; 85:1294 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  153. 153. Vantaggi della ketamina Minor ipotensione Possibilità di iniezione im – Lum Hee WC,Metias VF.Intramuscular ketamine in a parturient in whom preoperative intravenous access was not possible . Br. J. Anaesth. 2001; 86 Maggiore profondità anestetica » Gaitini L,Vaida S,Collins G,Somri M,Sabo E.Awareness detection during Caesarean section under general anaesthesia using EEG spectrum analysis .CAN J ANAESTH 1995 / 42: 5 / pp377-81 Minor necessità di analgesia postop Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  154. 154. Protezione emodinamica dallo stress dell’IOT Oppioidi a breve azione: » alfentanil 10 microgr/kg Gin, T, Ngan-Kee, W D,Siu YK,Stuart JC,Tan P, Lam KK.Alfentanil given immediately before induction of general anesthesia for cesarean section.AA 2000;90:1467. remifentanil 1-1.25 microgr/kg bolo lento o inf cont – Ma PAS – O'Hare R, McAtamney D,Mirakhur RK, Hughes D, Carabine U.Bolus dose of remifentanil for control of haemodynamic response to tracheal intubation during rapid sequence induction of anesthesia.BJA 1999;82:283. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  155. 155. Kan RE.Hughes S,Rosen MA,Kessin C,Preston PG,Lobo EP.Intravenous Remifentanil: Placental Transfer, Maternal and Neonatal Effects.Anesthesiology,98:1467-74, 1998 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  156. 156. Schaut DJ Sevoflurane inhalation induction for emergency caesarean section in a parturient with no intravenous 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)
  157. 157. Dopo il parto Anestesia/analgesia indifferente? A patto che non deprima la contrattilità uterina…….. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  158. 158. Risveglio Estubare solo alla ripresa di una normale ventilazione e normale funzione neuromuscolare! Controllare forza !! Se non avete ancora svuotato lo stomaco,fatelo prima del risveglio! » SNG/lavaggio/antiacido per contatto(citrato di sodio) Profilassi del PONV? » Valutazione dei fattori di rischio… » Tenete conto dedlla profilassi ab ingestis:ranitidina+metoclopramide Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  159. 159. THE END Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  160. 160. Chemioprofilassi dell’ab ingestis Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  161. 161. 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)
  162. 162. 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)
  163. 163. 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)
  164. 164. 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
  165. 165. 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)
  166. 166. 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)
  167. 167. 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
  168. 168. Morti materne associate con l’anestesia in milioni di gravidanze stimate per England & Wales 40 35 30 morti associate direttamente freq.per milione 25 20 15 % delle morti dirette 10 5 0 70- 73- 76- 79- 82- 85- 88- 91- 94- 9772 75 78 81 84 87 90 93 96 99 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  169. 169. Maternal deaths UK 1994-96 thrombosis PIH early pregn haemorrhage AFE Anaesthesia others Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  170. 170. Maternal deaths UK 1997-99 thrombosis PIH afe haemorrhage suicide sepsis Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  171. 171. New trends in UK maternal mortality Mort.rate among most disadvantaged groups;20 * Other than white :*2 Young<18 Increasing maternal age Increasing parity Obese In vitro fertilization Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  172. 172. Relative risk C/S 4,9> vag(C/S is an amalgamation of risk associated with the disorder for which surgery is indicated and the risk associated with the procedure itself…. Elective C/S 2.3 Emergent C/S 12.0 Instrum,vag delivery risk 3,1 vs vag deliv Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  173. 173. Maternal deaths due to anesthesia:CEMD 20 18 16 14 12 10 8 6 4 2 0 85-87 88-90 91-93 94-96 direct GA indirect Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  174. 174. Panchal et al.Maternal mortality during hospital admission for delivery:a retrospective analysis using a state maintained database.Anesth.Analg.2001;93:13441. Jan 1984-dec 1997 Maryland DRG C/S and vag.deliv,hospital only,anonymous Selected case controls 822.591 admissions for delivery 135 deaths Maternal deaths/100.000 5.92-29,6 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  175. 175. RISK factors(/100.000)(from Panchal et al) Age;from 13,9<34 to 23,9>34 Caucasion 7,6,african.americans 31,6,18,1 others African americans 5 times more prob to die during pregnancy than caucasian Social,cultural,economic,health care access,quality factors;multiple diagnoses and severity of illness ++ C/S 5,3 +;60% of deaths associated with C/S Minor teaching hospital 3,.1 + Transfer from another hospital 6,2+ Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  176. 176. Maryland more common causes of maternal mortality precl/eclamp postpartum hemorrh pulm Ko cvs event AFE/clot insuff prenatal care trauma Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  177. 177. MARYLAND STATISTICS on Maternal deaths;african american vs caucasian 30 25 20 african-american caucasian 15 10 5 0 precl/eclamp pulm Ko AFE/clot AC.RENAL FAIL Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  178. 178. 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)
  179. 179. 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)
  180. 180. Halper,SH et al.Effect of epidural vs parenteral opioid analgesia on the progress of labor.JAMA 1998;280:2105-2110 Metanalysis “epidural analgesia has a favourable effect on funic pH and BE suggesting that the known reduction in maternal stress and sympathetic tone do improve the intrauterine environment ,despite the theorethical potential adverse effects…” Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  181. 181. Decision-delivery interval The 30 min.rule Is this a standard that fetal distress cases be delivered within 30 min? Fetal hypoxia=scalp pH <7,2;serious disability when pH<7.00 Correlation between DD interval and neonatal asphyxia? Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  182. 182. DD interval…. C/S ;DD interval shorter with GA(DD 23),but umb.cord artery pH better with reg(DD 50). Br Med J 322,June 2001 McKenzie1334-35 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  183. 183. Reliability.CSE *C/S 1 0,9 0,8 0,7 QCH 1998 Norris 1994 Paech 1998 Albright 1999 0,6 % 0,5 0,4 0,3 0,2 0,1 0 failure rate Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  184. 184. GA is not the choice for obs emergencies necessary only for true emergencies Necessary only when: » poor teamwork, poor communication ,lack of reg skills Necessary only for some fetal conditions(tocolysis) GA risk in pregnancy greater GA not necessarily faster and faster my not be better………. – Crowhurst,2001 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  185. 185. Section: A Comparison of Time efficiency,Costs,Charges and Complications .Anesth Analg 1995; 80:709–12 Retrospective study from their cases C/S elective epidural (n = 47) or spinal (n = 47) anesthesia Patients who received epidural anesthesia had significantly longer total operating room (OR) times than those who received spinal anesthesia (101 ± 20 vs 83 ± 16 min, [mean ± SD] P < 0.001); this was caused by longer times spent in the OR until surgical incision (46 ± 11 vs 29 ± 6 min, P < 0.001). Length of time spent in the postanesthesia recovery unit was similar in both groups. Supplemental intraoperative intravenous (IV) analgesics and anxiolytics were required more often in the epidural group (38%) e Rianimazione Ospedale di Faenza(RA) Servizio di Anestesiathan in the spinal group (17%) (P < 0.05).
  186. 186. Spinal faster than epid….( Riley et al, Spinal Versus Epidural Anesthesia for Cesarean Section: A Comparison of Time Efficiency, Costs, Charges, and Complications.Anesth Analg 1995; 80:709–12) 120 100 80 min 60 epid spi 40 20 0 OR-incis total OR time Pacu time Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  187. 187. Drug(opioids,anxyolitics) consumption;spinal vs peridural (Riley et al, Spinal Versus Epidural Anesthesia for Cesarean Section: A Comparison of Time Efficiency, Costs, Charges, and Complications.Anesth Analg 1995; 80:709–12) 40 * * 35 30 25 % 20 15 I catete intravasc 1 catet intratecale 1 perf dura 3 insuff analg 10 5 0 intraop postop KO Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) epid spi
  188. 188. Direct costs($):Spi vs epid 45 40 35 kit needle drug morph fent nurses 13 min tot 30 25 20 15 10 5 0 spi epid Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  189. 189. Epid takes longer…….. Learning curve the anesthesiologist must progress more slowly with the epidural needle to avoid a dural puncture the epidural catheter must be threaded and taped a test dose must be given and the patient .observed for 3–5 min to exclude IV or intrathecal placement the entire local anesthetic dose must be administered incremental onset of epidural anesthesia is slower than that of spinal anesthesia. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  190. 190. Anesth prep time differed among groups( Glosten et al.Practical aspects of regional anesthesia for cesarean delivery,failure rates and anesthetic preparation times-An observational study..Anesthesiology 1995;83:A977. ): 70 60 50 40 GA EPI SPI % Min 30 20 10 0 failure rate anest prep time anest successful anest unsuccess Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  191. 191. Attitude in failed epidurals(Glosten et al.Practical aspects of regional anesthesia for cesarean delivery,failure rates and anesthetic preparation times-An observational study..Anesthesiology 1995;83:A977. ): Repeat EPI 4 SPI 11 AG 9 epi d f a i l u r e s ( 2 4/ 1 79) absent bl o ck 5 i n adeq blo ck 12 cat e t m is pla c 2( i v . ) par e st e si a 1 subdur a l 2 pat ie nt anxie t y 1 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  192. 192. Attitude in failed spinalsGlosten et al.Practical aspects of regional anesthesia for cesarean delivery,failure rates and anesthetic preparation times-An observational study..Anesthesiology 1995;83:A977. ): S p i fa ilu r e s (3 /9 8 ) in a b ilit y t o o b t a in C S F GA in t r a o p p a in Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  193. 193. USA changes in anesthesia for C/S( 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)
  194. 194. UK changes in obs.anesthesia(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)
  195. 195. Ben David B,Miller G,Gavriel R,Gurevitch A.Low dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery, Reg Anest PainMed.2000;25:235-39. 32 paz,20-40 anni isobaric bupi 0.5% 10 mg vs 5 mg+fent 25 microgr preload RL 500;intraop altri 800 ml sitting,26 g pencil point;2 ml in 10-15 sec. Poi supine + LLT efedrina 5-10 mg as needed tempo oper(dal’inizio della spi);<70 min tutti,eccetto 1. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  196. 196. Ben David et al.Low dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery, Reg Anest PainMed.2000;25:235-39. 100 0.001 90 80 0.05 70 min, 60 %, 50 mg 40 30 20 0.01 0.0002 0.0002 Liv medio T3 bupi 10 mg bupi 5 + fent 25 mu Liv medio T4-5 10 0 Meno blocco moto time to peak block misur ipotens nausea/vomito Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  197. 197. Vercauteren MP,Coppejans HC,Hoffmann VH,Mertens E,Adriaensen A.Prevention of hypotension by a single 5 mg dose of ephedrine during small dose spinal anesthesia in prehydrated cesarean delivery patients.AA 2000;90:324-327. Cimetidine p.o 900 mg 1 h prima della induzione RL 1000 ml iniziato 10’ prima del trasferimento in S.OP HES 6% 500 ml all’arrivo in sala op Induzione di CSE dec,.lat dx bupi 6,6 mg+sufent 3.3 microgr intratecale inserito catet pd doppio cieco efedr 5 mg vs placebo Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  198. 198. Steer, Phyllis L., MD*; Biddle, Chuck J., PhD*; Marley, Wanda S., CRNA MS*†; Lantz, Robert K., PhD‡; Sulik, Patricia L., PhD‡ From the Departments of Anesthesiology at University of Kansas,* Kansas City, Kansas, and Poudre Valley Hospital,† Ft. Collins, Colorado, Rocky Mountain Instrumental Laboratories, Inc.,‡ Fort Collins, Colorado. Research conducted at the Poudre Valley Hospital, Ft. Collins, Colorado. Address correspondence to: Dr. Phyllis L. Steer, University of Kansas Medical Center, 39th and Rainbow, Kansas City, Kansas 66103. Funded by the School of Allied Health, University of Kansas and Janssen Pharmaceutica. Accepted for publication 25th November, 1991. ABSTRACT: The purpose of this study was to measure the concentration of fentanyl in human colostrum after intravenous administration of an analgesic dose. Thirteen healthy women were given fentanyl 2 mg kg-1 for analgesic supplementation during either Caesarean section or postpartum tubal ligation. Serum and colostrum were collected for 45 min, two, four, six, eight, and ten hours following administration of the drug. Radioimmunoassay showed that colostrum fentanyl concentrations were greatest at 45 min, the initial sampling time, reaching 0.40 ± 0.059 ng ml-1, but were virtually undetectable ten hours later. Fentanyl concentrations were always higher in colostrum than in serum. This concluded that with these small concentrations and fentanyl's low oral bioavailability, intravenous fentanyl analgesia may be used safely in breast-feeding women. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  199. 199. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  200. 200. Vercauteren et al Prevention of hypotension by a single 5 mg dose of ephedrine during small dose spinal anesthesia in prehydrated cesarean delivery patients.AA 2000;90:324-327.Results 80 70 Livello T3 1 per ogni gruppo lidoc 2% p.d. 60 50 efedr 5 mg placebo 40 30 20 10 0 altra efedr ipotens<90 vomito Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  201. 201. 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 evaluate the effect of spinal and general anesthesia on blood coagulability in normal pregnant women undergoing cesarean section, using thromboelastography. In the spinal anesthesia group (n = 15), thromboelastography was performed after crystalloid preloading and during the immediate postanesthesia course. In the general anesthesia group (n = 15), thromboelastography was performed before Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  202. 202. Minimizzazione dell’anestesia materna(‘40-’60) “awareness” Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  203. 203. 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)
  204. 204. “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)
  205. 205. 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)
  206. 206. Domande: Potete ottenere una spinale nel + breve tempo possibile? Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  207. 207. 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)
  208. 208. 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)
  209. 209. 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)
  210. 210. Il significato di emergenza Diverso fra: anestesista ostetrico nurse paziente pediatra avvocato……o magistrato…………. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  211. 211. 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
  212. 212. 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)
  213. 213. 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)
  214. 214. 1992 ACOG Committee Opinion on Anesthesia for emergency deliveries The entire obstetric care team should be alert to the parturient at increased 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)
  215. 215. pressure during spinal anaesthesia for Caesarean section. Br J Anaesth 2004; 92:469-74. Editorial AUTHOR(S): Riley, E. T. My prediction is that within the next few years we will be treating hypotension after spinal anaesthesia in a fundamentally different way than we have during the last 20 years. We will no longer use ephedrine as the mainstay of treatment, we will be more aggressive about maintaining arterial pressure near normal, and we will worry less (if at all) about the liberal use of other vasoconstricting drugs. In another important contribution by this group, Ngan Kee and colleagues provide evidence that will help us determine the optimal way for preventing the detrimental effects of maternal hypotension after induction of spinal anaesthesia for Caesarean delivery. In this study, the authors maintained maternal arterial pressure at 80%, 90% or 100% of baseline. Using umbilical artery pH as their primary outcome, they found that maintaining the arterial pressure at 100% of baseline was associated with the best outcome for the baby (highest umbilical artery pH) and the mother (less nausea). Although it is not surprising that maintaining homeostasis is the best strategy, this study shatters the long-held notion that it is best to minimize the use of vasopressors in pregnant patients. It has long been held that vasoconstriction from predominantly alpha-adrenergic agonist drugs will decrease uterine blood flow (UBF) and be harmful to the fetus. Maintenance of low placental vascular resistance and thus better UBF was considered more important than any adverse effects resulting from a 20–30% decrease in maternal arterial pressure. How did the notion develop that it is better to let the arterial pressure drift down rather than risk placental vasoconstriction? Several sheep studies showed that large doses of vasoconstricting drugs decreased UBF. However, ephedrine maintained UBF much better than other pressors that are primarily vasoconstrictors and have little beta-agonist effect (e.g. phenylephrine and metaraminol). Therefore, ephedrine became the 'gold standard' for prophylaxis and treatment of spinal hypotension. Accumulating evidence that doses of ephedrine large enough to maintain homeostasis after the induction of spinal anaesthesia may be detrimental to the fetus are causing a major change in our approach to this problem. In a recent study, Cooper and colleagues compared ephedrine and phenylephrine for the treatment of maternal hypotension. Consistent with other recent studies, they found ephedrine caused more acidosis in the fetus. A unique aspect of Cooper and colleagues' study is their evaluation of the degree of acidosis seen in the umbilical vessels. They calculated the difference between the PCO2 in the umbilical artery and umbilical vein (PCO2 (art-vein)). If the PCO2 (art-vein) is small, this indicates poor placental perfusion or gas exchange. For example, conditions such as placental abruption have a small PCO2 (art-vein). If the PCO2 (art-vein) is large, this suggests that acidosis in the umbilical artery is secondary to a process in the fetus. Cooper and colleagues found a strong correlation between ephedrine use and an increase in the PCO2 (art-vein). From these data they concluded that ephedrine was stressing the fetus and may have contributed to fetal acidosis. There is additional evidence that ephedrine may adversely affect the fetus. When ephedrine was given to women in labour, there were changes in the fetal heart rate pattern (tachycardia and abnormal increases in variability) that might indicate fetal stress or an increase in fetal metabolic activity. These changes were dose related. Other commonly used vasopressors do not have as much beta-agonist activity and thus do not increase metabolism in the fetus. For example, Cooper and colleagues found no correlation between phenylephrine dose and an increase in the PCO2 (art-vein). The current study, as well as others by Cooper and colleagues and Mercier and colleagues, all reported use of large doses of phenylephrine given to maintain a baseline arterial pressure without any adverse effect on the fetus. Why do these large doses of phenylephrine (sometimes over 1000 mg total dose) not cause clinically significant vasoconstriction and decreased placental perfusion? Although these large doses were needed to maintain homeostasis, they did not increase arterial pressure to supranormal levels. Therefore, these doses should be considered appropriate for correcting the vasodilatation secondary to a spinal anaesthetic. The parturient's decreased sensitivity to sympathomimetics during pregnancy may help protect the fetus from excessive vasoconstriction. Tong and Eisenach demonstrated that uterine arteries from pregnant ewes were less responsive to vasoconstrictors compared with those from non-pregnant ewes. Giving large doses of alpha-agonists that constrict peripheral arteries and restore normal maternal arterial pressure may preferentially shunt blood to the uterine arteries, which may be relatively spared from the vasoconstrictive effect. We must also consider the possibility that significant placental vasoconstriction does occur with phenylephrine, but may not be important with regard to fetal wellbeing. Of particular interest in Ngan Kee and colleagues' article in the current issue is the trend for an increase in umbilical artery PO2 to occur in conjunction with higher maternal arterial pressures (although this did not quite reach statistical significance - P=0.058). This finding is consistent with my observations during ex utero intrapartum therapy procedures and fetal surgery. In these cases, the fetus is at least partially extracted from the uterus but not separated from the placenta. The fetus continues to be supported by the placenta while a procedure is performed. In all instances, a pulse oximeter probe was placed on the fetus. In Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  216. 216. Database dei “Closed claims”(richieste di risarcimento) per l’ awareness intraop 79 / 4183 claims;1.9% : » 18 richieste per awake paralysis(paralisi da svegli) paralisi involontaria di un paz cosciente » 61 richieste per ricordi durante GA :ricordo di eventi in corso di GA Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  217. 217. 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)
  218. 218. 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)
  219. 219. 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 association with depression. 1 patient experienced sleep disturbances afterward, but the other four patients did not have any after effects. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  220. 220. Approfondimenti sugli effetti degli anest.volatili sul feto ( e neonato subito dopo la nascita) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  221. 221. Dwyer, R.; Fee, J. P. H.; Moore, J. Uptake of halothane and isoflurane by mother and baby during cesarean section.BJA 1995;74:279 : Twenty–three patients undergoing Caesarean section received either 0.5% halothane or 0.8% isoflurane to supplement nitrous oxide–oxygen anaesthesia. We studied the rate of uptake of the agents by the mother and fetus by measuring partial pressures in maternal arterial (Pa) and fetal umbilical venous (Puv) blood. Mean induction– delivery interval did not differ between the halothane (10.8 min) and isoflurane (11.7 min) groups. There were no differences in maternal heart rate, arterial pressure, pH and blood–gas tensions and fetal pH, blood–gas tensions or Apgar scores between the two groups. Isoflurane uptake by the mother was more rapid than halothane; at delivery, mean Pa of isoflurane as a fraction of the inspired partial pressure (PI) was 0.44 compared with 0.35 for halothane (P < 0.05). Mean Puv as a fraction of maternal Pa at delivery was 0.71 for both agents; thus placental transfer was the same for both agents. Consequently mean Puv/PI was greater for isoflurane (0.32) than halothane (0.26) (P < 0.05). We conclude that both halothane and isoflurane are suitable agents for general anaesthesia for Caesarean section. The rate of uptake of isoflurane by the mother during Caesarean section was more rapid than halothane. The rate of uptake by the fetus from the mother was the same for halothane and isoflurane, so that fetal partial pressure as a fraction of the inspired partial pressure was greater for isoflurane than halothane. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  222. 222. rate of uptake of halothane and isoflurane by the mother and fetus by measuring partial pressures in maternal arterial (Pa) and fetal umbilical venous (Puv) blood Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  223. 223. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  224. 224. Wojtczak, Jacek A. 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 pulsed-Doppler velocity meter . Halothane, but not isoflurane, caused a significant decrease in cardiac stroke volume and maximum acceleration of blood (dV/dtmax), an index of cardiac performance. This effect was reversible, and during washout, stroke volume and dV/dtmax increased above control levels. Embryonic heart rate was not affected by either drug. Chick and human embryos are similar during early stages of development; therefore, chick embryo may be a useful model to study the cardiovascular effects of anesthetics. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

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