This study evaluated the effectiveness and side effects of different volumes of hyperbaric bupivacaine and sufentanil for spinal anesthesia in cesarean sections. Forty patients were divided into two groups receiving either 4 mL or 3 mL of the solution. Both groups received 10 mg of hyperbaric bupivacaine and 5 μg of sufentanil. The 4 mL group had longer analgesia duration with no increase in side effects. Higher volumes of this solution provided better postoperative analgesia without maternal-fetal complications.
Este documento describe los dispositivos de entrada, salida e entrada/salida de un computador. Entre los dispositivos de entrada se incluyen el teclado, mouse, joystick, lápiz óptico y micrófono. Los dispositivos de salida son el monitor, altavoz e impresora. Algunos dispositivos de entrada/salida son el módem, fax y USB.
O documento discute as continuidades e rupturas nos movimentos estudantis brasileiros. Apresenta o movimento estudantil como um movimento social sui generis, com características próprias. Realiza uma análise cíclica das ações estudantis no Brasil e avalia as principais características dos movimentos estudantis contemporâneos no país.
Este documento presenta el plan de acción mundial sobre la salud de los trabajadores 2008-2017 adoptado por la 60a Asamblea Mundial de la Salud de la OMS. El plan busca promover la salud y seguridad de los trabajadores a nivel mundial a través de tres objetivos: 1) elaborar e implementar marcos normativos nacionales sobre salud laboral, 2) fortalecer la prevención de riesgos laborales y 3) mejorar el acceso a servicios de salud ocupacional. Los países miembros de la OMS se comprome
Este documento resume o sistema cardiovascular e seus principais componentes: vasos sanguíneos, coração e sangue. Descreve a circulação do sangue no corpo, incluindo a circulação pulmonar e sistêmica, e explica doenças e fatores que afetam o sistema. Uma experiência é proposta para simular os componentes do sangue.
Este documento describe los dispositivos de entrada, salida e entrada/salida de un computador. Entre los dispositivos de entrada se incluyen el teclado, mouse, joystick, lápiz óptico y micrófono. Los dispositivos de salida son el monitor, altavoz e impresora. Algunos dispositivos de entrada/salida son el módem, fax y USB.
O documento discute as continuidades e rupturas nos movimentos estudantis brasileiros. Apresenta o movimento estudantil como um movimento social sui generis, com características próprias. Realiza uma análise cíclica das ações estudantis no Brasil e avalia as principais características dos movimentos estudantis contemporâneos no país.
Este documento presenta el plan de acción mundial sobre la salud de los trabajadores 2008-2017 adoptado por la 60a Asamblea Mundial de la Salud de la OMS. El plan busca promover la salud y seguridad de los trabajadores a nivel mundial a través de tres objetivos: 1) elaborar e implementar marcos normativos nacionales sobre salud laboral, 2) fortalecer la prevención de riesgos laborales y 3) mejorar el acceso a servicios de salud ocupacional. Los países miembros de la OMS se comprome
Este documento resume o sistema cardiovascular e seus principais componentes: vasos sanguíneos, coração e sangue. Descreve a circulação do sangue no corpo, incluindo a circulação pulmonar e sistêmica, e explica doenças e fatores que afetam o sistema. Uma experiência é proposta para simular os componentes do sangue.
La primera generación de computadoras abarcó desde 1938 hasta 1958 y utilizó tecnología basada en tubos de vacío. Estas primeras computadoras funcionaban con lenguaje de máquina, el nivel más bajo de comunicación posible.
Este documento habla sobre la memoria ROM y sus características. La memoria ROM almacena información de forma permanente sin necesidad de corriente eléctrica. Incluye diferentes tipos de memoria ROM como el BIOS, cargador de arranque, CMOS y configuración. También describe la capacidad, duración de la información y tipos de memoria de sólo lectura como ROM, PROM, EPROM, EEPROM y memoria flash.
El documento describe varias herramientas digitales y sus usos en educación. Microsoft Office se usa para editar documentos. Jclic y CD Rayuela crean actividades educativas. Hot Potatoes y Cmap Tools crean actividades de evaluación y mapas conceptuales para asignaturas como español, matemáticas, ciencias naturales e historia. Kidpedia provee información en línea y Google Maps crea mapas personalizados para historia y geografía. Educaplay crea actividades y blogs se usan para difundir conocimientos. Las herramientas digitales mejoran la
Este documento describe los servicios de calidad que ofrece Roncalli, un Centro Especial de Empleo, incluyendo servicios de impresión, mailing, embolsado, retractilado de publicaciones y distribución postal. Roncalli ofrece estos servicios a precios competitivos utilizando su capacidad de producción y su plantilla compuesta principalmente por personas con discapacidad. Los clientes contratan a Roncalli no solo por cumplir con la ley de discapacidad, sino por la calidad y el precio de sus servicios.
Este documento define a los vampiros como criaturas muertas en vida que se alimentan de sangre para mantenerse con vida y evitar la luz del sol. Explora el origen de los primeros vampiros y describe su personalidad como hermosa pero atormentada con el deseo de sangre. También cubre temas como su lugar de origen en Transilvania, su necesidad de matar para sobrevivir y cómo son representados en películas para diferentes géneros y edades.
El documento proporciona información sobre un estudiante llamado Carlos Arcaya A. con C.I. 13.106.844 que está estudiando Ingeniería de Mantenimiento Mecánico. El documento se refiere a un ejercicio de ecuaciones lineales para el curso de Álgebra Lineal realizado en junio de 2014.
Este documento presenta definiciones básicas sobre conceptos de muestreo. Define elementos, población, unidades de muestreo, marco y muestra. Explica que el muestreo es necesario debido a que realizar un censo de toda la población suele ser muy costoso y lento, mientras que el muestreo permite obtener resultados más rápidos y económicos con menor error.
José Feliciano es un cantante y guitarrista puertorriqueño ciego de nacimiento que se ha destacado por fusionar géneros musicales como el bolero, balada, folk, blues y rock. Comenzó su carrera en los años 1960 versionando canciones en inglés que tuvieron éxito internacional. Más tarde se volcó a interpretar boleros en español que también resultaron muy populares. A lo largo de su trayectoria ha demostrado su versatilidad musical al tocar diversos instrumentos y cantar en varios idiomas.
El Gatopato, un animal mitad gato y mitad pato, se sentía triste y solo porque los demás animales se burlaban de él. Un día decidió ocultar parte de su cuerpo de pato para hacerse pasar por un gato y ganar amigos. Cuando cayó al agua y reveló su verdadera naturaleza, los peces casi no lo ayudan por miedo. Finalmente, lo rescatan y desde entonces es aceptado y feliz con sus nuevos amigos.
El documento habla sobre HTML. Explica que HTML es el lenguaje de marcado usado para crear páginas web y define su estructura básica y código. Luego describe que las etiquetas de HTML se escriben entre símbolos < y > y explican su propósito, como <B> para negrita o <IMG> para imágenes. Finalmente lista algunos colores comunes de HTML que se pueden escribir en lugar de sus códigos.
Subarachnoid Block With Low Dose Bupivacaine And Fentanyl In Elderly Hyperten...lgmitra01
This study assessed the effects of low-dose subarachnoid block with bupivacaine and fentanyl in elderly hypertensive female patients undergoing vaginal hysterectomy. Sixty-two patients were randomly assigned to receive either 12.5 mg bupivacaine alone or 7.5 mg bupivacaine with 25 mg fentanyl. The combination led to a faster onset and longer duration of sensory blockade without prolonging motor blockade. It also resulted in fewer episodes of hypotension, less need for vasopressors, and longer duration of postoperative analgesia. The low-dose combination provided effective spinal anesthesia with improved hemodynamic stability and pain relief.
This document describes a randomized clinical trial that aims to compare the incidence of blocking all three nerves (femoral, lateral femoral cutaneous, and obturator nerves) when performing ultrasound-guided fascia iliaca compartment block using either a supra-inguinal approach versus an infra-inguinal approach. Sixty patients undergoing lower limb surgery will be randomly assigned to receive the block using one of the two approaches. The primary outcome is the incidence of a three-nerve block, while secondary outcomes include time of nerve block onset and distance of injection point from the inguinal ligament.
This randomized controlled trial evaluated the efficacy and safety of buccal buprenorphine film for chronic low back pain in opioid-experienced patients. Patients underwent an opioid taper and then open-label titration with buccal buprenorphine before being randomly assigned to continued buprenorphine or placebo. Patients receiving buprenorphine had significantly greater reductions in pain scores compared to placebo over 12 weeks. The most common adverse event with buprenorphine was vomiting. This study demonstrates the efficacy and tolerability of buccal buprenorphine for chronic low back pain in patients taking around-the-clock opioids.
1. This study investigated the incidence of abdominal pain in patients receiving remifentanil versus fentanyl for anesthesia during cataract surgery.
2. The study found that 52.6% of patients who received remifentanil experienced postoperative abdominal pain, compared to only 2% of patients who received fentanyl.
3. Severe abdominal pain requiring intervention occurred in 6.7% of remifentanil patients but none of the fentanyl patients. The cause of remifentanil-induced abdominal pain is unknown.
The study compared the haemodynamic effects of propofol versus desflurane during remifentanil-based anesthesia for pediatric ENT surgery requiring controlled hypotension. Forty-one children were randomly assigned to receive either propofol/remifentanil or desflurane/remifentanil. The targeted hypotension was achieved in most cases for both groups, though MAP below 50 mmHg occurred more frequently with desflurane and MAP above 65 mmHg occurred more frequently with propofol. Hemodynamic stability was less maintained when desflurane and remifentanil were used compared to propofol-remifentanil. Both methods provided satisfactory surgical conditions though desflurane required more fluid resusc
Les NVPO sont un événement fréquent en post-anesthésie puisqu'ils touchent environ un tiers des patients. Les différents scores et prophylaxies utilisées bien que souvent efficaces ne closent pas le chapitre de leur prévention. La gabapentine, antivonvusilvant, a montré par ailleurs son effet analgésique en post-opératoire.
Plus récemment, la gabapentine a montré un effet anti-émétique lorsqu'elle était administrée en prévention dans la chimiothérapie du cancer du sein.
Cette étude est une méta-analyse des essais randomisés de la gabapentine en prévention des NVPO. Elle conclut à son efficacité, efficacité d'autant plus marquée que le propofol n'est pas utilisé comme agent d'induction et/ou d'entretien.
Peran Fentanyl pada balance anestesia -> telah banyak diteliti hasilnya adanya potensiasi fentanyl dengan obat anestesia baik inhalasi maupun intravena. Berikut ini kami mencoba menelaah beberapa penelitian dari luar maupun penelitian yang kami lakukan sendiri.
La primera generación de computadoras abarcó desde 1938 hasta 1958 y utilizó tecnología basada en tubos de vacío. Estas primeras computadoras funcionaban con lenguaje de máquina, el nivel más bajo de comunicación posible.
Este documento habla sobre la memoria ROM y sus características. La memoria ROM almacena información de forma permanente sin necesidad de corriente eléctrica. Incluye diferentes tipos de memoria ROM como el BIOS, cargador de arranque, CMOS y configuración. También describe la capacidad, duración de la información y tipos de memoria de sólo lectura como ROM, PROM, EPROM, EEPROM y memoria flash.
El documento describe varias herramientas digitales y sus usos en educación. Microsoft Office se usa para editar documentos. Jclic y CD Rayuela crean actividades educativas. Hot Potatoes y Cmap Tools crean actividades de evaluación y mapas conceptuales para asignaturas como español, matemáticas, ciencias naturales e historia. Kidpedia provee información en línea y Google Maps crea mapas personalizados para historia y geografía. Educaplay crea actividades y blogs se usan para difundir conocimientos. Las herramientas digitales mejoran la
Este documento describe los servicios de calidad que ofrece Roncalli, un Centro Especial de Empleo, incluyendo servicios de impresión, mailing, embolsado, retractilado de publicaciones y distribución postal. Roncalli ofrece estos servicios a precios competitivos utilizando su capacidad de producción y su plantilla compuesta principalmente por personas con discapacidad. Los clientes contratan a Roncalli no solo por cumplir con la ley de discapacidad, sino por la calidad y el precio de sus servicios.
Este documento define a los vampiros como criaturas muertas en vida que se alimentan de sangre para mantenerse con vida y evitar la luz del sol. Explora el origen de los primeros vampiros y describe su personalidad como hermosa pero atormentada con el deseo de sangre. También cubre temas como su lugar de origen en Transilvania, su necesidad de matar para sobrevivir y cómo son representados en películas para diferentes géneros y edades.
El documento proporciona información sobre un estudiante llamado Carlos Arcaya A. con C.I. 13.106.844 que está estudiando Ingeniería de Mantenimiento Mecánico. El documento se refiere a un ejercicio de ecuaciones lineales para el curso de Álgebra Lineal realizado en junio de 2014.
Este documento presenta definiciones básicas sobre conceptos de muestreo. Define elementos, población, unidades de muestreo, marco y muestra. Explica que el muestreo es necesario debido a que realizar un censo de toda la población suele ser muy costoso y lento, mientras que el muestreo permite obtener resultados más rápidos y económicos con menor error.
José Feliciano es un cantante y guitarrista puertorriqueño ciego de nacimiento que se ha destacado por fusionar géneros musicales como el bolero, balada, folk, blues y rock. Comenzó su carrera en los años 1960 versionando canciones en inglés que tuvieron éxito internacional. Más tarde se volcó a interpretar boleros en español que también resultaron muy populares. A lo largo de su trayectoria ha demostrado su versatilidad musical al tocar diversos instrumentos y cantar en varios idiomas.
El Gatopato, un animal mitad gato y mitad pato, se sentía triste y solo porque los demás animales se burlaban de él. Un día decidió ocultar parte de su cuerpo de pato para hacerse pasar por un gato y ganar amigos. Cuando cayó al agua y reveló su verdadera naturaleza, los peces casi no lo ayudan por miedo. Finalmente, lo rescatan y desde entonces es aceptado y feliz con sus nuevos amigos.
El documento habla sobre HTML. Explica que HTML es el lenguaje de marcado usado para crear páginas web y define su estructura básica y código. Luego describe que las etiquetas de HTML se escriben entre símbolos < y > y explican su propósito, como <B> para negrita o <IMG> para imágenes. Finalmente lista algunos colores comunes de HTML que se pueden escribir en lugar de sus códigos.
Subarachnoid Block With Low Dose Bupivacaine And Fentanyl In Elderly Hyperten...lgmitra01
This study assessed the effects of low-dose subarachnoid block with bupivacaine and fentanyl in elderly hypertensive female patients undergoing vaginal hysterectomy. Sixty-two patients were randomly assigned to receive either 12.5 mg bupivacaine alone or 7.5 mg bupivacaine with 25 mg fentanyl. The combination led to a faster onset and longer duration of sensory blockade without prolonging motor blockade. It also resulted in fewer episodes of hypotension, less need for vasopressors, and longer duration of postoperative analgesia. The low-dose combination provided effective spinal anesthesia with improved hemodynamic stability and pain relief.
This document describes a randomized clinical trial that aims to compare the incidence of blocking all three nerves (femoral, lateral femoral cutaneous, and obturator nerves) when performing ultrasound-guided fascia iliaca compartment block using either a supra-inguinal approach versus an infra-inguinal approach. Sixty patients undergoing lower limb surgery will be randomly assigned to receive the block using one of the two approaches. The primary outcome is the incidence of a three-nerve block, while secondary outcomes include time of nerve block onset and distance of injection point from the inguinal ligament.
This randomized controlled trial evaluated the efficacy and safety of buccal buprenorphine film for chronic low back pain in opioid-experienced patients. Patients underwent an opioid taper and then open-label titration with buccal buprenorphine before being randomly assigned to continued buprenorphine or placebo. Patients receiving buprenorphine had significantly greater reductions in pain scores compared to placebo over 12 weeks. The most common adverse event with buprenorphine was vomiting. This study demonstrates the efficacy and tolerability of buccal buprenorphine for chronic low back pain in patients taking around-the-clock opioids.
1. This study investigated the incidence of abdominal pain in patients receiving remifentanil versus fentanyl for anesthesia during cataract surgery.
2. The study found that 52.6% of patients who received remifentanil experienced postoperative abdominal pain, compared to only 2% of patients who received fentanyl.
3. Severe abdominal pain requiring intervention occurred in 6.7% of remifentanil patients but none of the fentanyl patients. The cause of remifentanil-induced abdominal pain is unknown.
The study compared the haemodynamic effects of propofol versus desflurane during remifentanil-based anesthesia for pediatric ENT surgery requiring controlled hypotension. Forty-one children were randomly assigned to receive either propofol/remifentanil or desflurane/remifentanil. The targeted hypotension was achieved in most cases for both groups, though MAP below 50 mmHg occurred more frequently with desflurane and MAP above 65 mmHg occurred more frequently with propofol. Hemodynamic stability was less maintained when desflurane and remifentanil were used compared to propofol-remifentanil. Both methods provided satisfactory surgical conditions though desflurane required more fluid resusc
Les NVPO sont un événement fréquent en post-anesthésie puisqu'ils touchent environ un tiers des patients. Les différents scores et prophylaxies utilisées bien que souvent efficaces ne closent pas le chapitre de leur prévention. La gabapentine, antivonvusilvant, a montré par ailleurs son effet analgésique en post-opératoire.
Plus récemment, la gabapentine a montré un effet anti-émétique lorsqu'elle était administrée en prévention dans la chimiothérapie du cancer du sein.
Cette étude est une méta-analyse des essais randomisés de la gabapentine en prévention des NVPO. Elle conclut à son efficacité, efficacité d'autant plus marquée que le propofol n'est pas utilisé comme agent d'induction et/ou d'entretien.
Peran Fentanyl pada balance anestesia -> telah banyak diteliti hasilnya adanya potensiasi fentanyl dengan obat anestesia baik inhalasi maupun intravena. Berikut ini kami mencoba menelaah beberapa penelitian dari luar maupun penelitian yang kami lakukan sendiri.
rakshat syn presentation.pptx for learniRakshatNayak1
This document presents a research proposal that aims to compare the analgesic effect of two different doses of intrathecal nalbuphine hydrochloride with 0.5% hyperbaric bupivacaine for lower abdominal surgeries. The study will involve 150 patients randomized into three groups receiving different combinations of intrathecal bupivacaine and nalbuphine. Outcome measures will include onset of sensory and motor blockade, duration of analgesia, and hemodynamic parameters. A literature review found that intrathecal nalbuphine prolongs postoperative analgesia without increasing side effects when used as an adjuvant to bupivacaine. The results of this study may provide insights into
This study compared neonatal and maternal outcomes following administration of fentanyl and midazolam or placebo to 60 pregnant women prior to Cesarean section under spinal anesthesia. The study found:
1) No significant differences between groups in neonatal Apgar scores, neurobehavioral scores, or continuous pulse oximetry measurements over three hours.
2) Mothers who received fentanyl and midazolam were more likely to report finding the study medication helpful, but both groups showed no difference in recall of the birth.
3) Maternal catecholamine levels and neonatal cord blood gas values were similar between groups.
The study concluded that a single dose of fentanyl and mid
This document summarizes a study examining the effects of calcium channel blockers cinnarizine and nifedipine alone and in combination with antiepileptic drugs sodium valproate and carbamazepine in seizure models. The study found that cinnarizine and nifedipine alone showed anticonvulsant effects. When combined with sodium valproate, cinnarizine and nifedipine significantly increased protection against seizures compared to sodium valproate alone. Specifically, the combination of cinnarizine and sodium valproate showed 100% protection against maximal electroshock seizures, while nifedipine and sodium valproate showed 100% protection against p
Abstracts of different published research related to homoeopathy medical scie...DrAnkit Srivastav
This document provides abstracts from 23 published studies on the efficacy of homeopathy for treating various medical conditions in humans. The studies included randomized controlled trials and observational studies on conditions such as dental neuralgia, post-operative pain/agitation in children, respiratory infections, hay fever, liver cirrhosis, thalassemia, fibromyalgia, migraine, hypertension, asthma, anal fissures, lactation pain, optic neuropathy, peripheral neuropathy, pruritus in haemodialysis patients, mild traumatic brain injury, plantar fasciitis, and menopausal hot flushes. Many of the studies found homeopathy to be more effective than placebo in reducing symptoms and improving health outcomes.
This document discusses the advantages of using remifentanil for day surgery anesthesia. It notes that remifentanil provides rapid recovery due to its short context-sensitive half-life, metabolism independent of organs, and flexibility from light sedation to deep analgesia. Studies presented show remifentanil results in faster times to eye opening, extubation, orientation and recovery of cognitive function compared to other opioids like fentanyl or alfentanil. Remifentanil also allows for reduced inhalational agent doses and faster discharge from ambulatory surgery settings.
1) The study assessed whether epidural chloroprocaine affects the pain relief provided by epidural morphine after cesarean delivery.
2) Forty women were randomly assigned to receive either epidural chloroprocaine or a placebo, followed by epidural morphine.
3) The study found no difference between the groups in the duration of pain relief from the morphine, pain levels, or need for additional pain medication, suggesting that chloroprocaine does not reduce the effectiveness of epidural morphine for post-cesarean analgesia.
This document discusses the perioperative management of patients taking buprenorphine/naloxone (Suboxone) for opioid use disorder. It reviews the pharmacology of buprenorphine and indications for its use. For perioperative management, the evidence is mixed but the document provides opinions based on surgical factors like pain level and use of regional anesthesia as well as patient factors. Abrupt cessation of buprenorphine can cause precipitated withdrawal while higher opioid doses may be needed for pain control if buprenorphine is continued in the perioperative period. A multidisciplinary approach is recommended.
Newer Trends and Recent Advances in Parasympathomimetics and parasympatholyticsShubham Marbade
It describes about newer trends and Recent Advances in Parasympathomimetics and parasympatholytics and their mechanism of actions
by Shubham marbade
Department of Pharmacology
A Comparative Study between Caudal Bupivacaine (0.25%) And Caudal Bupivacaine...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
1) The onset of spinal block is more rapid with isobaric bupivacaine than hyperbaric bupivacaine when used in a combined spinal-epidural technique.
2) Both isobaric and hyperbaric bupivacaine at a dose of 9.75 mg produced adequate upper levels of analgesia for surgery, reaching around thoracic vertebrae 7.
3) The duration of motor block recovery was around 2.5 hours with both forms of bupivacaine, making them compatible for ambulatory surgery. Subsequent epidural injections of lidocaine provided minimal increases in sensory block in most patients.
This document discusses new developments in controlled ovarian stimulation (COS) protocols. It outlines several new forms of fertility drugs including long acting FSH, FSH biosimilars, and subcutaneous progestagens. It also describes new COS protocols such as those using fewer injections, flexibility in start dates, dual stimulation, and individualizing FSH dosing to prevent ovarian hyperstimulation syndrome. The document concludes that while further research is still needed, these new drugs and protocols provide valuable options for increasing flexibility and optimizing outcomes in ART treatment.
Magnesium sulfate (MgSO4) has several uses in obstetrics including seizure prophylaxis in preeclampsia/eclampsia and providing fetal neuroprotection. It works through vasodilation and reduction of inflammation. Common regimens include IV/IM loading doses followed by IV or IM maintenance doses over 24 hours. Shorter durations of 4 hours or a single IM dose postpartum have also been shown to be effective for seizure prophylaxis. MgSO4 protects the fetal brain through action as an NMDA receptor blocker and its anti-inflammatory effects, decreasing brain lesions and improving long-term outcomes in preterm newborns. It is recommended for neuroprotection for preterm births before 32 weeks
Similar to 14.1.anestesia espinal con_10_mg_de_bupivacaina_hiperbarica_asociada_con_[1] (20)
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
1. Rev Bras Anestesiol ARTIGO CIENTÍFICO
2010; 60: 2: 121-129 SCIENTIFIC ARTICLE
Anestesia Espinhal com 10 mg de Bupivacaína Hiperbárica
Associada a 5 μg de Sufentanil para Cesariana. Estudo
de Diferentes Volumes *
Spinal Block with 10 mg of Hyperbaric Bupivacaine Associated
with 5 µg of Sufentanil For Cesarean Section. Study of Different Volumes
Angélica de Fátima de Assunção Braga, TSA1, José Aristeu Fachini Frias, TSA2, Franklin Sarmento da Silva Braga3,
Daniela Roncoletta da Silva Pinto4
RESUMO CONCLUSÕES: A bupivacaína hiperbárica na dose de 10 mg asso-
Braga AFA, Frias JAF, Braga FSS, Pinto DRS – Anestesia Espinhal ciada ao sufentanil na dose de 5 µg, com volume de 4 mL, foi mais
com 10 mg de Bupivacaína Hiperbárica Associada a 5 μg de Sufen- eficaz que a mesma associação em menor volume (3 mL), propor-
tanil para Cesariana. Estudo de Diferentes Volumes. cionando melhor analgesia intra e pós-operatória, sem repercussões
materno-fetais.
JUSTIFICATIVA E OBJETIVOS: Diversos fatores influenciam na dis-
persão cefálica da solução anestésica no espaço subaracnóideo, en- Unitermos: ANESTÉSICO, Local: bupivacaína hiperbárica; CIRUR-
tre os quais destacam-se as alterações fisiológicas inerentes à gravi- GIA, Obstétrica: cesariana; TÉCNICAS ANESTÉSICAS, Regional:
dez, baricidade, dose e volume do anestésico local. O objetivo deste subaracnóidea.
estudo foi avaliar em cesarianas a efetividade e os efeitos colaterais
de diferentes volumes da associação de bupivacaína hiperbárica e
SUMMARY
sufentanil por via subaracnóidea.
Braga AFA, Frias JAF, Braga FSS, Pinto DRS – Spinal Block with 10
mg of Hyperbaric Bupivacaine Associated with 5 µg of Sufentanil for
MÉTODO: Quarenta pacientes, ASA I e II, submetidas à cesariana
Cesarean Section. Study of Different Volumes.
eletiva sob raquianestesia distribuídas em dois grupos, de acordo
com o volume da solução anestésica empregada: Grupo I (4 mL) e
BACKGROUND AND OBJECTIVES: Several factors affect the ce-
Grupo II (3 mL). Nos dois grupos o anestésico local empregado foi
phalad dispersion of the anesthetic solution in the subarachnoid spa-
a bupivacaína hiperbárica (10 mg-2 mL) associada ao sufentanil (5
ce; among them, physiological changes of pregnancy and the dose
µg-1 mL). No Grupo I, para obtenção do volume de 4 mL, foi adiciona-
and volume of the local anesthetics should be mentioned. The objec-
do 1 mL de solução fisiológica a 0,9%. Foram avaliados: latência do
tive of this study was to assess the effectivity and side effects of diffe-
bloqueio; nível máximo do bloqueio sensitivo; grau do bloqueio motor;
rent volumes of the subarachnoid administration of the association of
tempo para regressão do bloqueio motor; duração total da analgesia;
hyperbaric bupivacaine and sufentanil in cesarean sections.
efeitos adversos maternos e repercussões neonatais.
METHODS: Forty patients, ASA I and II, undergoing elective cesare-
RESULTADOS: A latência, o nível máximo do bloqueio sensitivo, o grau an section under spinal block were divided in two groups, according
e o tempo para regressão do bloqueio motor foram semelhantes nos to the volume of the anesthetic solution: Group I (4 mL) and Group II
dois grupos; a duração da analgesia foi maior no Grupo I, com diferença (3 mL). The association of hyperbaric bupivacaine (10 mg-2 mL) and
significativa em relação ao Grupo II. Os efeitos adversos ocorreram com sufentanil (5 µg-1 mL) was used in both groups. In Group I, 1 mL of
frequência semelhante em ambos os grupos. Ausência de alterações NS was added to the solution to achieve the volume of 4 mL. The
cardiocirculatórias maternas e repercussões neonatais. following parameters were evaluated: latency of the blockade; upper
limit of the sensorial blockade; degree of motor blockade; time for re-
gression of the motor blockade; total duration of analgesia; maternal
* Recebido (Received from) ddo Departamento de Anestesiologia da Faculdade
de Ciências Médicas (FCM) da Universidade de Campinas (UNICAMP), SP
side effects; and neonatal repercussions.
1. Professora Associada – Livre-Docente; Responsável pela Seção de Anest- RESULTS: Latency, the upper limit of the sensorial blockade, and
esia – CAISM/ UNICAMP the degree and time for regression of the motor blockade were simi-
2. Anestesiologista – CAISM/UNICAMP lar in both groups; duration of analgesia was greater in Group I than
3. Professor Doutor; Chefe do Departamento de Anestesiologia da FCM/UNI- in Group II, which was statistically significant. The incidence of side
CAMP
effects was similar in both groups. Maternal cardiocirculatory changes
4. Anestesiologista; Ex-Residente do Departamento de Anestesiologia da
FCM/UNICAMP
and neonatal repercussions were not observed.
Apresentado (Submitted) em 13 de agosto de 2009 CONCLUSIONS: Four milliliter of anesthetic solution composed of
Aceito (Accepted) para publicação em 24 de dezembro de 2009 hyperbaric bupivacaine, 10 mg, associated with 5 µg of sufentanil was
more effective than 3 ml of the same solution, providing better intra-
Endereço para correspondência (Correspondence to): and postoperative analgesia without maternal-fetal repercussions.
Dra. Angélica de Assunção Braga
Rua Luciano Venere Decourt, 245
Cidade Universitária
Keywords: ANESTHETIC, Local: hyperbaric bupivacaine; ANES-
13083-740 Campinas, SP THETIC TECHNIQUE, Regional: subarachnoid; SURGERY, Obste-
E-mail: franklinbraga@terra.com.br tric: cesarean section.
Revista Brasileira de Anestesiologia 121
Vol. 60, No 2, Março-Abril, 2010
2. Spinal Block With 10 Mg of Hyperbaric Bupivacaine Associated with 5 µg of Sufentanil For
Cesarean Section. STUDY OF DIFFERENT VOLUMES
Spinal Block with 10 mg of Hyperbaric
Bupivacaine Associated with 5 µg of
Sufentanil For Cesarean Section. Study
of Different Volumes
Angélica de Fátima de Assunção Braga, TSA, M.D; José
Aristeu Fachini Frias, TSA, M.D.; Franklin Sarmento da Silva
Braga, M.D.; Daniela Roncoletta da Silva Pinto, M.D.
INTRODUCTION
Spinal blocks with disposable, low caliber spinal needles and
the use of 0.5% hyperbaric bupivacaine associated with ad-
juvant became the technique of choice for elective cesarean
sections and in urgent and emergency situations1. In partu-
rients at term, the different mechanisms that influence disper-
sion of the local anesthetic (LA) in the subarachnoid space are
exacerbated by the physiological changes of pregnancy, whi-
ch, consequently, contribute for the higher incidence of mater-
nal-fetal complications, especially maternal hypotension. The
dose of the LA, an important factor in the determination of the
level and duration of the sensorial blockade, as well as the
intensity and duration of the motor blockade, can be reduced
as a consequence of the changes seen during pregnancy and
the association of adjuvant, especially liposoluble opioids. On
the other hand, the volume and concentration of the hyperba-
ric anesthetic solutions can also affect those parameters, but
they are secondary to those related to the dose of the LA2-9.
Addition of opioids to hyperbaric bupivacaine in spinal blocks
reduces the latency, prolongs significantly the duration, and
improves the efficacy of analgesia when compared to isola-
te bupivacaine7,9. The objective of the present study was to
assess the effectivity of different volumes of the association
of hyperbaric bupivacaine and sufentanil in the quality of the
blockade and maternal-fetal repercussions in parturients un-
dergoing elective cesarean sections.
METHODS
This study was undertaken after approval by the Medical and
Research Ethics Committee of the institution and signing of the
Revista Brasileira de Anestesiologia 125
Vol. 60, No 2, Março-Abril, 2010
3. BRAGA, FRIAS, BRAGA ET AL.
informed consent. This is a clinical, randomized, double-blind as- sensorial blockade – evaluate 20 minutes after the administration
say, in which consecutive gravidas at term, physical status ASA I of the anesthetic solution; 3) maximal motor blockade – evaluated
and II, undergoing elective cesarean sections under spinal block, every 20 minutes after the administration of the anesthetic solution,
were enrolled. Exclusion criteria were as follows: pre-eclampsia, according to the methodology proposed by Bromage10: 1 = inca-
physical status ASA III and IV, prematurity, multiple gestation, pable of moving feet or knees (complete); 2 = capable of moving
and contraindications to the spinal block. only the feet (almost complete); 3 = capable of moving feet or knees
The size of the sample was based on the results of Chung et (partial); 4 = complete extension of the knees and feet (absent); 4)
al.6, considering the difference of 34 ± 26.8 minutes among time until total regression of the motor blockade – time between the
the means of the sensorial blockade in L5 (GI x GIII), in which blockade and free movement of the lower limbs (4 – absent); 5)
Group I – 0.25 bupivacaine (3.2 to 3.6 mL), and Group III – total duration of analgesia – time from the blockade until the first
0.25% bupivacaine (4.0 to 4.4 mL). Assuming this difference for spontaneous complaint of pain (NVS ≥ 3) in the immediate pos-
the Student t test, considering a significance of 5% (α = 0.05) toperative period, determined by the numeric verbal scale (NVS);
and a test power of 80% (β = 20%), the calculated size of the 6) maternal cardiocirculatory and respiratory parameters: systolic
sample population was of 11 individuals in each group, but we blood pressure (SBP – mmHg), heart rate (HR – bpm), respiratory
included 20 individuals in each group to compensate for pos- rate (bpm), and oxygen saturation (SpO2 – %) were evaluated at
sible losses. Therefore, 40 patients were randomly divided, the following moments: before the blockade (M0); immediately after
using the SAS 9.1 software and a uniform distribution with p = the blockaded (M1); every five minutes during the surgery (M2); at
0.50 – probability of 50% to be included in Group I (volume = 4 the end of the surgery (M3); and at the time of discharge from the
mL) and 50% to be included in Group II (volume= 3 mL). post anesthetic recovery room (M4); 7) intraoperative maternal side
One of the authors prepared the anesthetic solution and per- effects: nausea, vomiting, pruritus, somnolence, respiratory depres-
formed the blockade, which were unknown to the anesthesio- sion (SpO2 ≤ 90% and respiratory rate lower than 10 bmp); and 8)
logist who evaluated the parameters investigated. neonatal repercussions: Apgar on the first and fifth minutes.
In both groups, a fixed dose of 10 mg (2 mL) of 0.5% hyperbaric Hypotension was defined as the reduction in systolic blood
bupivacaine associated with sufentanil (5 μg – 1 mL) was used. pressure greater than 20% of baseline levels or below 100
One milliliter of NS was added to the solution used in Group I mmHg in the first 30 minutes after the blockade, which would
to obtain a volume of 4 mL. The drugs used were commercial be treated with rapid crystalloid infusion followed by the admi-
products provided by the same manufacturer, without the lot nistration of ephedrine (5 mg – intravenous bolus) if the pa-
number. The density of the solutions was analyzed in the la- tient did not respond to the crystalloid infusion; bradycardia
boratory of the manufacturer using a digital densitomer Anton was defined as a heart rate below 50 bpm, treated with atropi-
Paar model DMA 4500 calibrated with milli-Q water at 37° C. ne (0.01-0.02 mg.kg-1).
Table I shows the characteristics of the resulting solutions. Duration of the surgery (minutes) – it was defined as the time
Besides the subarachnoid block, the epidural space was punc- between the incision of the skin and the end of the surgery;
tured in both groups, and a catheter was introduced for intra- fetal extraction time (minutes) – time between the beginning
operative complaints of pain and maintenance of adequate of the surgery and removal of the fetus.
analgesia during the surgery. The criterion for anesthetic su- The Student t test was used to evaluate the latency of the
pplementation with LA through the catheter was: patient com- blockade, duration of analgesia, and time for regression of the
plaining of pain (NVS ≥ 3), in which case the use of 0.25% bupi- motor blockade; Fisher exact test was used for the degree of
vacaine with vasoconstrictor (12.5 mg) was recommended. the motor blockade and level of the sensorial blockade. In the
Patients were fasting and pre-anesthetic medication was not ad- analysis of the cardiocirculatory and respiratory parameters,
ministered. In the operating room, all patients were monitored with moment M2 was considered the mean of the levels obtained
cardioscope on the DII derivation, non-invasive blood pressure, during the surgery at five-minute intervals, which was analyzed
and pulse oximeter. After establishing an intravenous access with by MANOVA. A level of significance of 5% was established.
an 18G catheter before the blockade, 500 to 750 mL of Ringer’s
lactate were administered. With patients in the sitting position, the
epidural puncture was carried out with a 16G Tuohy needle in the RESULTS
L2-L3 space and an epidural catheter was inserted in the cephalad
direction. A 25G Quincke needle, introduced in the L3-L4 space, was Significant differences in the physical characteristics of the
used for the subarachnoid block, and the anesthetic solution was patients were not observed between both groups (Table II).
injected at a rate of 1 mL.25 secs-1 without barbotage. After the blo- Mean surgery and extraction times and standard deviations
ckade, patients were placed in horizontal dorsal decubitus, using were, respectively, 83.40 ± 26.21 and 18.0 ± 5.62 minutes, in
a Crawford wedge to dislocate the uterus to the left until delivery. Group I (4 mL), and 75.70 ± 16.89 and 17.55 ± 5.88 minutes,
Oxygen (2 to 5 L.min-1) was administered through a nasal cathe- in Group II (3 mL), without statistically significant differences
ter. Hydration was maintained with the administration of Ringer’s between both groups.
lactate (10 mL.kg-1.h-1). The following parameters were evaluated: Latency of the sensorial blockade was similar in both groups;
1) latency of the sensorial blockade – time from the end of the injec- maximal upper limit of the blockade ranged from T2 to T6, with
tion of anesthetic solution in the arachnoid space (assessed every a predominance of T4, without statistically significant differen-
minute) to the loss of pin prick sensation in T10; 2) upper limit of the ces; grade 1 (complete) motor blockade predominated, and
126 Revista Brasileira de Anestesiologia
Vol. 60, No 2, Março-Abril, 2010
4. SPINAL BLOCK WITH 10 MG OF HYPERBARIC BUPIVACAINE ASSOCIATED WITH 5 °G OF SUFENTANIL FOR
CESAREAN SECTION. STUDY OF DIFFERENT VOLUMES
time for reversal of the motor blockade did not show statis- Table I – Characteristics of the Anesthetic Solutions
tically significant differences; total duration of analgesia was Group I Group II
significantly higher in Group 1 (Table III). Three patients (pa-
Volume (mL) 4 3
tients 05, 09, and 12) in Group II (3.0 mL) required intraope-
Density at 37ºC (g.mL-1) 1.01223 ± 0.00013 1.01632 ± 0.00027
rative supplementation of LA through the epidural catheter, at
80, 92, and 71 minutes, respectively (Figure 1). Bupivacaine (mg)
The respiratory rate of all patients remained above 10 breaths Total dose 10 10
per minute, and oxygen saturation between 95% and 100%. Glucose (mg.mL-1) 40 53.3
Hemodynamic repercussions were similar in both groups. Sig-
nificant differences were not observed when mean SBP and Table II – Characteristics of the Patients
HR at the different study moments were compared between
Group I (4 mL) Group II (3 mL) p
the study groups (p = 0.08). In the individual analysis of the
(n = 20) (n = 20)
cardiocirculatory parameters, hypotension was seen in 11
Age (years)* 30.05 ± 5.436 28.90 ± 6.78 0.3
(55%) patients, in GI, and 10 (50%) in GII, at M2 (intraoperati-
ve), corrected by the administration of ephedrine (10 mg). Weight (kg)* 83.55 ± 14.52 79.49 ± 13.24 0.6
Apgar in the first and fifth minutes ranged from 8 to 9 (GI) and 8 to Height (m)* 1.60 ± 0.06 1.58 ± 0.05 0.28
10 (GII), respectively. Table IV shows the mean incidence of intra- BMI (kg.m-2)* 32.54 ± 5.3 31.96 ± 5.32 0.77
operative maternal side effects, which was similar in both groups. Results expressed as Mean ± SD
* Student t test
Table IV – Side Effects Table III – Characteristics of the Blockade
Group I (4,0 mL) Group II (3,0 mL)
Group I Group II
Nausea 03 (15%) 04 (20%) p
(4 mL) (3 mL)
Vomiting 01 (5%) 02 (10%) Latency (min)* 4.15 ± 1.11 4.63 ± 1.91 0.1
Pruritus 10 (50%) 10 (50%) Degree of the motor blockade** 0.3
Somnolence 12 (60%) 08 (40%) 2 1 2
Results expressed as number and percentage of patients 1 19 18
T2 5 (25%) 2 (10%)
T4 14 (70%) 16 (80%)
DISCUSSION T6 1 (5%) 2 (10%)
Time for regression of the 191.65 ± 189.55 ± 0.89
In obstetrics, the association of bupivacaine and liposo- motor blockade (min)* 47.23 56.4
luble opioids in subarachnoid blocks decreased the inci- Total duration of 298.35 ± 196.55 ±
dence of intraoperative visceral pain and contributed for a analgesia (min.)* 48.99# 68.68 0.0001
reduction in the doses of hyperbaric bupivacaine (8.0 to Results expressed as Mean ± SD; number of patients; % – percentage of patients
10 mg)8,11. A prior study with gravidas undergoing spinal #significant difference in relation to Group II
*Student t test, **Fisher exact test
block for cesarean section showed that the use of constant
concentrations of hyperbaric bupivacaine (0.25%) and in-
creasing volumes, leading, consequently, to a progressive and properties of the CSF; injection technique; puncture level,
increase in mass, resulted in significant cephalad disper- caliber and bevel of the needle, turbulent flow caused by the
sion of the drug and better intra- and postoperative analge- rate of the injection, and barbotage; and anesthetic solution:
sia, without significant difference in motor blockade6. Ho- density, viscosity, volume, concentration, dose of the LA, and
wever, the effectivity of low doses, in different volumes and the association with vasoconstrictors. Additionally, positioning
concentrations, of the association of local anesthetic and of the patient at the moment of the puncture and afterwards
opioids in determining maximal upper level and quality of also affect dispersion3-5,12-14.
the sensorial blockade, as well as the degree of the motor Note that, on term pregnancy, the increase in abdominal pres-
blockade, has not been clearly defined in gravidas under- sure and engorgement of epidural veins, with reduction in the
going cesarean sections. volume of the CSF in the lumbar and lower thoracic regions,
In the present study, artifices that could affect the cephalad contribute for greater cephalad dispersion of anesthetic solu-
dispersion of the hyperbaric anesthetic solution were avoided. tions. Besides, due to the lower concentration of proteins, the
Patients remained in the sitting position during the puncture, density of the CSF at 37° C is reduced (1.00003 ± 0.0004)
and in horizontal dorsal decubitus after the slow administra- on term pregnancies when compared to normal individuals
tion (1 mL.25 secs-1) of the anesthetic solution. (1.00007 ± 0.0003)2,15.
The dispersion mechanism of local anesthetics in the CSF is The anesthetic solution is considered hyperbaric when its
multifactorial, involving patient characteristics: age, weight, density exceeds 99% the confidence limit of the density of the
height, gender, abdominal pressure, anatomy of the spine, CSF16. All glucose-free anesthetic solutions with bupivacaine
Revista Brasileira de Anestesiologia 127
Vol. 60, No 2, Março-Abril, 2010
5. BRAGA, FRIAS, BRAGA ET AL.
500
400
Time in minutes
300
200
100
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Number of patients
Group I Group II
Figure 1 – Duration of Analgesia. Individual Values (minutes) in Both Groups
and opioid are considered hypobaric after subarachnoid admi- This conduct allowed supplementation of the local anesthetic
nistration unlike glucose-containing solutions, which, even in in three patients of Group II who complained of pain during
low concentrations, remain hyperbaric12. revision of the cavity, therefore avoiding the use of high doses
In a clinical study with patients undergoing cesarean sections of opioids and sedatives, as well conversion to general anes-
with 0.5% bupivacaine (2.5 mL) in two solutions with diffe- thesia. It was also observed that, in those cases, the duration
rent concentrations of glucose (8 mg.mL-1 and 80 mg.mL-1), of the surgery was above the mean values obtained for this
the authors observed that, at 37° C, both solutions are ma- parameter.
thematically hyperbaric (1.00164 ± 0.0.00008 and 1.02081 ± Although significant differences in the level of the sensorial
0.00017, respectively), and the clinical characteristics of the blockade were not observed, the longer time of analgesia and
blockade, as well as the quality of the surgical blockade did better quality of analgesia in Group I can be attributed to the
not show statistically significant differences between the study cephalad dispersion of bupivacaine and sufentanil, involving
groups17. a higher number of non-myelinated C fibers, which transmit
Diluting hyperbaric bupivacaine with opioids and NS not only visceral pain, therefore increasing analgesic potency11,20.
decreases its density18,19, but also decreases its viscosity, Similarly to clinical studies that used 7.5 and 11 mg of hyper-
facilitating cephalad dispersion14,17. In the present study, we baric bupivacaine, the degree and time for regression of the
used two hyperbaric solutions with different densities. Besi- motor blockade were not influenced by the volume of the
des, according to the clinical characteristics of the blockade anesthetic solution6,21.
observed in this study , along with the results of a recent la- It has been observed, in urologic procedures, that the suba-
boratorial study, it has been confirmed that the solutions were rachnoid administration of a fixed dose (10 mg) of hyperbaric
hyperbaric, since solutions with densities below 1, equal to 1, bupivacaine in different volumes and concentrations (0.5%,
and greater than 1 are considered hypobaric, isobaric, and 0.2%, and 0.1%) caused similar sensorial blockades, but the
hyperbaric, respectively16. degree and duration of the motor blockade were significantly
The relationship among the mass, volume, and concentra- higher when the concentration of 0.5% was used22.
tion of the anesthetic solution is inseparable, i.e., mass is In cesarean sections, the incidence of hypotension associa-
the result of volume x concentration; therefore, changing ted with subarachnoid block ranges from 50 to 85%13. In stu-
the volume, but not the concentration, changes the mass of dies with isolate hyperbaric bupivacaine, in concentrations of
the anesthetic. Studies with hyperbaric bupivacaine without 0.25% and 0.5% isolated, in different volumes, a higher inci-
opioids showed that, although the volume interferes with dence of hypotension was associated with changes in volu-
the dispersion of the solution in the subarachnoid space, me, not in doses6,13,20. In the present study, using fixed doses,
mass is the most important element, especially in partu- but different volumes and concentrations, the incidence of hy-
rients at term5,6. potension was similar in both groups.
Assessment of the total analgesia time demonstrated that, in Differences were not observed in the Apgar scores of the new-
all patients in Group I, total anesthesia time remained above borns, and the results of maternal side effects were similar to
200 minutes, while in Group II this was observed only in 50% those reported in the literature7,9,20.
of the cases (Figure 1). Although subarachnoid block is widely The results of the present study allow us to conclude that, in
used in cesarean sections, in the present study we also de- cesarean sections, the subarachnoid administration of greater
cided to place a catheter in the epidural space of all patients. volumes of the anesthetic solution containing fixed doses of
128 Revista Brasileira de Anestesiologia
Vol. 60, No 2, Março-Abril, 2010
6. SPINAL BLOCK WITH 10 MG OF HYPERBARIC BUPIVACAINE ASSOCIATED WITH 5 °G OF SUFENTANIL FOR
CESAREAN SECTION. STUDY OF DIFFERENT VOLUMES
hyperbaric bupivacaine (10 mg) and sufentanil (5 μg) were 19. Cangiani LM – Determinação da densidade e da baricidade das
more effective than lower volumes of the same solution, pro- misturas para anestesia subaracnóidea. Rev Bras Anestesiol,
2000;50:92-94
viding better duration and quality of analgesia without increa- 20. Balki M, Carvalho JCA – Intraoperative nausea and vomiting during
sing maternal-fetal repercussions. cesarean section under regional anesthesia. Int J Obstet Anaesth,
2005;14:230-241.
21. Kiran S, Singal NK – A comparative study of three different doses of
0.5% hyperbaric bupivacaine for spinal anaesthesia in elective cae-
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06. Chung CJ, Bae SH, Chae KY et al. – Spinal anaesthesia with 0,25% JUSTIFICATIVA Y OBJETIVOS: Diversos factores influyen en la
hyperbaric bupivacaine for Caesarean section: effects of volume. Br J dispersión cefálica de la solución anestésica en el espacio suba-
Anaesth, 1996;77:145-149. racnoideo, entre los cuales se destacan las alteraciones fisiológi-
07. Dahlgren G, Hultstrand C, Jakobsson J et al. – Intrathecal sufenta-
cas inherentes al embarazo, baricidad, dosis y volumen del anes-
nil, fentanyl, or placebo added to bupivacaine for cesarean section.
tésico local. El objetivo de este estudio fue evaluar la efectividad
Anesth Analg, 1997;85:1288-1293.
08. Choi DH, Ahn HJ, Kim MH – Bupivacaine-sparing effect of fentanyl y los efectos colaterales de diferentes volúmenes de la asociación
in spinal anesthesia for cesarean delivery. Reg Anesth Pain Med, de bupivacaína hiperbárica y sufentanil por vía subaracnoidea en
2000;25:240-245. cesáreas.
09. Braga AF, Braga FS, Potério GM et al. – Sufentanil added to hyper-
baric bupivacaine for subarachnoid block in Caesarean section. Eur J MÉTODO: Cuarenta pacientes, ASA I y II, sometidos a cesárea elec-
Anaesthesiol, 2003;20:631-635. tiva bajo raquianestesia distribuidos en dos grupos, de acuerdo con el
10. Bromage PR – A comparasion of the hydrochloride and carbon diox- volumen de la solución anestésica usada: Grupo I (4 mL) y Grupo II (3
ide salts of lidocaine and prilocaine in epidural analgesia. Acta Anaes- mL). En los dos grupos, el anestésico local empleado fue la bupivaca-
thesiol Scand, 1965;16(Suppl.):55-69. ína hiperbárica (10 mg-2 mL) asociada al sufentanil (5 µg-1 mL). En
11. Pedersen H, Santos AC, Steinberg ES et al. – Incidence of visceral
el Grupo I, para la obtención del volumen de 4 mL, se añadió 1 mL de
pain during cesarean section: the effect of varying doses of bupiva-
solución fisiológica a 0,9%. Se evaluaron: latencia del bloqueo; nivel
caine. Anesth Analg, 1989;69:46-49.
máximo del bloqueo sensitivo; grado del bloqueo motor; tiempo para
12. Hallworth SP, Fernando R, Columb MO et al. – The effect of posture
and baricity on the spread of intrathecal bupivacaine for elective ce- regresión del bloqueo motor; duración total de la analgesia; efectos
sarean delivery. Anesth Analg, 2005;100:1159-1165. adversos maternos y repercusiones neonatales.
13. Simon L, Boulay G, Ziane AF et al. – Effect of injection rate on hy-
potension associated with spinal anesthesia for cesarean section. Int RESULTADOS: La latencia, el nivel máximo del bloqueo sensitivo, el
J Obstet Anaesth, 2000;9:10-14. grado y el tiempo para la regresión del bloqueo motor fueron similares
14. McLeod GA – Density of spinal anaesthetic solutions of bupivacaine, en los dos grupos; la duración de la analgesia fue mayor en el Grupo
levobupivacaine and ropivacaine with and without dextrose. Br J I, con una diferencia significativa con relación al Grupo II. Los efectos
Anaesth, 2004;92:547-551. adversos se dieron a menudo de forma similar en los dos grupos. Se
15. Richardson MG, Wissler RN – Density of lumbar cerebrospinal fluid in registró la ausencia de las alteraciones cardiocirculatorias maternas
pregnant e nonpregnant humans. Anesthesiology, 1996;85:326-330.
y de las repercusiones neonatales.
16. Imbelloni LE, Moreira AD, Gaspar FC et al. – Avaliação da densidade
dos anestésicos locais e da combinação com adjuvantes. Estudo em
laboratório. Rev Bras Anestesiol, 2009;59:154-165.
CONCLUSIONES: La bupivacaína hiperbárica en dosis de 10 mg
17. Connolly C, McLeod GA, Wildsmith JAW – Spinal anaesthesia for asociada al sufentanil en dosis de 5 µg, con un volumen de 4 mL,
Caesarean section with bupivacaine 5 mg.ml-1 in glucose 8 or 80 fue más eficaz que la misma asociación en un menor volumen (3
mg.ml-1. Br J Anaesth, 2001;86:805-807. mL), proporcionando una mejor analgesia intra y postoperatoria, sin
18. Hare GMT, Ngan JCS – Density determination of local anaesthetic opioid repercusiones materno-fetales.
mixtures of spinal anaesthesia. Can J Anaesth, 1998;45:341-346.
Revista Brasileira de Anestesiologia 129
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