This document discusses inhalational anesthesia for cesarean sections. It provides background on trends showing a decrease in general anesthesia and increase in regional anesthesia for C-sections over time in the US and UK. It also discusses modifications in anesthesia due to pregnancy, such as decreased MAC values. The document focuses on techniques for general anesthesia, including agent choices, advantages and disadvantages of various halogenated agents, and methods to attenuate maternal stress responses. It notes the rare risk of maternal awareness during general anesthesia and closed claims data showing awareness is more common in women under 60 and ASA I.
Get Rid of Your Traditional Acute Pain Service and Broaden Your Vision!Edward R. Mariano, MD
Our biggest challenge (and also opportunity) is to demonstrate our value as anesthesiologists and pain medicine specialists in the evolving healthcare landscape. Going forward, physician anesthesiologists need to take on leadership roles in coordinating patient care, including by not limited to pain medicine, by collaborating with primary care, surgery, nursing, physical therapy, pharmacy, social work, and other hospital-based services.
Get Rid of Your Traditional Acute Pain Service and Broaden Your Vision!Edward R. Mariano, MD
Our biggest challenge (and also opportunity) is to demonstrate our value as anesthesiologists and pain medicine specialists in the evolving healthcare landscape. Going forward, physician anesthesiologists need to take on leadership roles in coordinating patient care, including by not limited to pain medicine, by collaborating with primary care, surgery, nursing, physical therapy, pharmacy, social work, and other hospital-based services.
Banner Promocional del Taller de CIAP 2 a realizarse el Jueves 22 de mayo de I0.30 a I2.00 en el 8º Congreso Uruguayo de Medicina Familiar y Comunitaria en Maldonado.
Valut az rischio anest sia napoli dic 2008;italian + bibliografyClaudio Melloni
evaluation of operative risk for non cardiac surgery ;for anesthesia and surgery.Cardiac conditions,including heart failure ,use of betablockers,stains.Diabetes risk,including difficult intubation.Thromboembolic risk,
lowest heart rate
lowest mean arterial pressure
estimated blood loss
A score built from these 3 predictors has proved strongly predictive of the risk of major postoperative complications and death in general and vascular surgery
A new dantrolene formulation for the treatment of Malignant hyperthermia(MH).Receptors,pharmacokinetics,dosages,preparation of dantrolene,practical tips,advantages.
This presentation was shown to Professor Toradse to help him remember about his life as a physics student in Georgia, (Tblisi) TSU and about his times as a professor of physics at UCV.
Banner Promocional del Taller de CIAP 2 a realizarse el Jueves 22 de mayo de I0.30 a I2.00 en el 8º Congreso Uruguayo de Medicina Familiar y Comunitaria en Maldonado.
Valut az rischio anest sia napoli dic 2008;italian + bibliografyClaudio Melloni
evaluation of operative risk for non cardiac surgery ;for anesthesia and surgery.Cardiac conditions,including heart failure ,use of betablockers,stains.Diabetes risk,including difficult intubation.Thromboembolic risk,
lowest heart rate
lowest mean arterial pressure
estimated blood loss
A score built from these 3 predictors has proved strongly predictive of the risk of major postoperative complications and death in general and vascular surgery
A new dantrolene formulation for the treatment of Malignant hyperthermia(MH).Receptors,pharmacokinetics,dosages,preparation of dantrolene,practical tips,advantages.
This presentation was shown to Professor Toradse to help him remember about his life as a physics student in Georgia, (Tblisi) TSU and about his times as a professor of physics at UCV.
Recent evidence based guideline regarding Ovarian drilling very helpful for Gynaecologist, laparoscopic surgeon, Infertility specialist, Post doctoral fellows and post graduates
Discusses cancer risk from low-dose radiation from medical imaging and how this applies to young or pregnant patients.
Describes MRI and ultrasound applications for pregnant patients to provide high quality diagnostic information without radiation.
Nora e reversal colorato slideshare; NaPoli i SIA 2016Claudio Melloni
Non operating room anesthesia and reversal of muscle relaxation.Respiratory complications due to residual paralysis.Mechanism of action of residual paralysis .Sugammadex.Calabadion New discoveries.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
1. 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)
2. 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)
3. 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)
4. 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)
5. 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)
6. 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
7. 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)
8. Topics
Indications
Contraindications
Side effects
Transplacentar passage:
» effects on the fetus and neonate
potentiating GA:reasons for:catecholamine reduction……
Crawford??
Obstetrical manoeuvers…
Emergency CS
Awareness avoidance—closed claims….
How:nearly all halogenated are equal…MAC properties
Side effects
Hypotension…but avoidance of aortocaval compression…
Nausea & vomiting
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
9. Indications for GA in OBS
Anesthesia personnel inexperienced in providing regional
anesthesia
Patient refusal of reg
Patient not cooperative
any istance of contraindications to regional anesth:
» infection:localized(dorsum) vs generalized(sepsis)….
» Coagulopathy:
emergency:foetal distress,placenta praevia,maternal haemorrhage,
urgent obstetrical manoeuvers …….
Hypovolemia….
Certain forms of heart disease that cannot tolerate
hypotension:fixed cardiac output;e.g.severe aortic
stenosis,Eisenmenger syndr.
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
10. Parekh N,Husaini SWU,Russell IFCaesarean section for
placenta praevia:a retrospective study of anesthetic
management.Br.J.Anaesth. 2000;84:723-30.
All anesth from 1 genn 1984 to 31/12/1998.
350 cases of plac previa:
» 60% Reg / 40% AG
» plc accreta;7 cases; 4 REG , 3 AG:but 2 reg convert.to
AG…5 hysterect.
» PA control during haemorrhage not a problem
» Ra assoc.with less blood loss
» “This retropectuve study do not support the often quoted
motto that plac.praevia calls for AG….”.
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
11. Disadvantages of GA
Asleep & unaware(late maternal bonding…)
husband less likely to be allowed in OR
drug depression of fetus
stress response to intubation
increased postoperative morbidity
cardiovascular changes of intubation
danger of aspiration(intubation & extubation)
difficult intubation
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
13. Ga:technique:II
IOT
check lung expansion,bilat.
N20 50% + halog 0.6 Mac
after delivery:repeat hypnotic + analgesic;stop volatile
Oxytocin 10-20 UI/lt,drip…
extubate awake and cooperative,having ascertained
the full return of nm function…
plan for failed intubation
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
14. Indications for halogenated
anesthetics
potentiating GA:reasons
for:catecholamine reduction……
Crawford??
Reduction or avoidance of
maternal awareness,patient asleep
and unaware
optimum operating conditions
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
16. Halogenated
agents:advantages..
allow use of increased O2
concentrations
may increase uterine blood flow by
decreasing maternal catecholamine
mediated uterine artery constriction
prevents awareness…but a few minutes
are needed before the attainment of a
reasonable MAC…(sevorane or desflurane
more rapid equilibration!
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
18. Modifications that affect inhalation
anesthesia in pregnancy
pain and discomfort thresholds
MAC requirements 25%‑40%.
FRC
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
20. Mac and pregnancy
Mac for inhalational agents decresed by
pregnancy(Datta et al,Chronically
administered progesterone decreases
halothane requirements in
rabbits.Anesth.Analg. 1989;68:46-50)
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
21. 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)
22. MAC reduction in pregnancy
Gin T, Chan MTV: Decreased minimum alveolar concentration of isoflurane in pregnant humans.
ANESTHESIOLOGY 81:829-32, 1994 ;& Chan et al.
Minimum Alveolar Concentration of Halothane and Enflurane Are Decreased in Early Pregnancy
Anesthesiology 85:782-6, 1996
1,8
1,6
1,4
1,2
1
0,8
isoflurane
halothane
enflurane
0,6
0,4
0,2
0
non pregnant
pregnant
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
24. 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)
26. Rise in alveolar(Fa) anesthetic concentration toward
the inspired(Fi) concentration
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
27. 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)
28. Navarro II
No diff among the 3 groups except a
more rapid emergence following des.
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
29. 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)
32. 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
33. Uterine blood flow changes during
anesth.in the pregnant ewe(from
Shnider,Levinson,etc..)
20
15
10
5
% change from
0
control
-5
-10
-15
-20
N2O 50%
N2O 50% +haloth 0.5%
N2O 50% + enfl 1%
anest without stim
anest with
stimulation
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
34. 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)
35. Lyons G, Macdonald R: Awareness during caesarean section.
Anaesthesia 46:62-4, 1991
1982-1989
> 3000 patients
questioned about recall and dreaming after general
anaesthesia for Caesarean section
28 (0.9%) patients were able to recall something of
their operation
189 (6.1%) reported dreams. Recollections of surgery
were confined to manipulations, noises and voices.
None of our patients complained of pain at the time of
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
36. Incidence of awareness(from various
sources)
16
14
12
10
C/S
card.surg
non card. Surg
major trauma
% 8
6
4
2
0
0.4
incidence
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
37. Domino K, Posner KL, Caplan, R,Cheney F. Awareness
during Anesthesia : A Closed Claims Analysis.Anesthesiology
90:1053-61, 1999.
Liability risk
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
38. Closed claim database for
intraoperative awareness
79 over 4183 claims;1.9% :
» 18 claims for awake paralysis(inadvertent paralysis of
an awake patient
» 61 claims for recall during GA :recall of events while
receiving general anesthesia
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
39. 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)
40. 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)
41. Dwyer R, Bennett HL, Eger EI II, Peterson N: Isoflurane
anesthesia prevents unconscious learning. Anesth Analg
75:107-12, 1992
Several authors report prevention of conscious recall
of events by relatively small concentrations of volatile
anesthetics. Isoflurane in concentrations of 0.6 MAC
prevented conscious recall and
unconscious learning of factual information
and behavioral suggestions.
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
42. Ranta S, Laurila R,Saario J,Ali-Melkkilä T, Hynynen M.
Awareness with Recall During General Anesthesia: Incidence
and Risk Factors Anesth Analg 1998; 86:1084
4818 operations under GA: 2612 (54%) patients were
interviewed
10 (0.4% of those interviewed) patients were found to
have undisputed awareness
9 (0.3%) patients with possible awareness.
The doses of isoflurane (P < 0.01) and propofol (P <
0.05) were smaller in patients with awareness.
5 patients with awareness underwent a psychiatric
evaluation;possible associtation with depression.
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
43. Moir, D. D .ANAESTHESIA FOR CAESAREAN SECTION An
Evaluation of a Method using Low Concentrations of Halothane
and 50 per cent of Oxygen Br. J. Anaesth. 1998; 80:690-696
The addition of 0.5 per cent of halothane vapour to a
basic thiopentone, nitrous oxide, muscle relaxant
anaesthetic technique does not increase blood loss at
Caesarean section, does not affect the incidence of
hypotension, and is likely to ensure unconsciousness.
By permitting the administration of 50 per cent of
oxygen with nitrous oxide, the condition of the
newborn infant is likely to be improved. The use of 0.8
per cent of halothane vapour does not increase blood
loss but is associated with a high incidence of
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
44. Elective C/S:Duration of GA or Epidural antepartum and % of
Apgar scores between 7-10
100
90
80
70
60
% 7-10
50
Apgar scores
40
30
20
10
0
(da dati di Robin,Shnider,Levinson---)
Min:
<5
6;10
11;20
21;30
31;60
GA
epid
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
45. I-D & UI-D
But more importantly than overall
duration between induction and delivery
(I-D) is the
uterine incision-delivery interval(UI-
D),that has been shown to correlate
with fetal hypoxia and acidosis
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
46. GA and neonatal depression
100
90
80
70
60
50
40
30
20
10
0
spinal
epidural
GA
Apgar 1'
Apgar 5'
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
47. Fetal-neonatal effects of
halogenated vapours
ONG BY,Cohen MM,Palahniuk
RJ:Anesthesia for cesarean section:
effects on neonates.Anesth.Analg
1989;68:270-275.
Greater requirements for neonatal
intubation and resuscitation versus
regional block in urgent C/S
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
48. Ong BY,Cohen MM,Palahniuk RJ.Anesthesia for cesarean
section:effects on neonates.AA 1989;68:270-5.
3940 C/S;12.5% of neonates Apgar < 4
1.5% 5 min Apgar score < 4
list of factors associated with low 1 min Apgar scores:
primiparity
grand multiparity
antepartum disease(preeclampsia,diabetes mellitus,maternal heart disease RH
isoimmunization, early amtepartum haemorrhage)
presence of fetal distress
low gestational age
use of narcotics during labor
breech presentation
nonelective C/S
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
49. Ong et al.Anesthesia for cesarean
section:effects on neonates.AA 1989;68:270-5.
Multivariate analysis that controlled for
many variables gave:
Higher risk of low apgar at 1 min GA 3
>reg(2.5-3.88)
Higher risk of low Apgar at 5 min; GA 3>
reg(1.81-7)
need for resuscitation: GA 2> reg(1.322.90)
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
50. Neonatal outcome after C/S by anesthetic technique:infants
with 1 min Apgar score < 4 (%)
Ong BY,Cohen MM,Palahniuk
RJ.Anesthesia for cesarean section:effects on neonates.AA 1989;68:270-5.
0.01
45
40
35
30
elective
0.001
25
fetal distress
failure to progress
20
15
10
0.05
5
0
reg
GA
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
51. Infants with 5 min Apgar score 0-4(%)
Ong BY,Cohen MM,Palahniuk
RJ.Anesthesia for cesarean section:effects on neonates.AA 1989;68:270-5.
0.01
9
8
7
6
5
0.01
4
3
2
elective
fetal distress
failure to progress
1
0
reg
GA
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
52. Neonates requiring oxygen by mask(%)
Ong BY,Cohen MM,Palahniuk
RJ.Anesthesia for cesarean section:effects on neonates.AA 1989;68:270-5.
0.001
25
20
0.01
15
elective
fetal distress
failure to progress
10
5
0
reg
GA
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
53. Neonates requiring iot and IPPV(%)
Ong BY,Cohen MM,Palahniuk
RJ.Anesthesia for cesarean section:effects on neonates.AA 1989;68:270-5.
0.001
45,0
40,0
35,0
30,0
elective
fetal distress
failure to progress
25,0
20,0
15,0
10,0
5,0
0,0
reg
GA
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
54. Gregory FA, Wagde JG, Biehl DR, Ong BY, Sitar DS. Foetal anaesthetic
requirements (MAC) for halothane. Anesth Analg 1983;62:9 ‑ 14.
Bachman CR, Biehl DR, Sitar DS, Cumming M, Pucci W. Isoflurane potency and
cardiovascular effects during short exposures in the foetal lamb. Can Anaesth Soc
J 1986;33:41‑ 7.
MAC is significantly lower in fetal lambs
than in lambs more than 24 hours of age.
These findings suggest that neonates
immediately after birth may be quite
sensitive to inhalation anesthetics so that
those exposed to general anesthetic agents
may be less vigorous at birth. After assisted
respirations and expiration of the anesthetic
agents, these infants appear to resemble
other infants,
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
55. Neonatal deaths
Ong BY,Cohen MM,Palahniuk RJ.Anesthesia for cesarean
section:effects on neonates.AA 1989;68:270-5.
7
6
5
4
elective
fetal distress
failure to progress
3
2
1
0
reg
GA
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
56. Postpartum blood loss:Piggott SE,Bogod DG,Rosen M,Rees
GAD,Harmer M.Isoflurane with either 100% oxygen or 50%
nitrous oxide in oxygen for caesarean section.BJA 1990;65:32529.
0,0
-5,0
HB decrease,
%
-10,0
-15,0
elective
emergent
0% +
1,2%
0% +
ur 1,7
00%+
loth
,75
-25,0
2O
aloth
.5
-20,0
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
57. Influence of anesthesia on blood loss at C/S(Moir DD.Anesthesia for
cesarean section:an evaluation of a method using low concentrations of halothane and 50% of
oxygen.BJA 1970;42:136-142.
800
700
600
500
N2O 70
N2O50+ aloth 0,5
N2O 50+ haloth 0,8
epid analg
ml 400
300
200
100
0
blood loss
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
58. HCT values before and after C/S:(from Thirion et al.Maternal blood loss
associated with low dose alothane administration for caesarean section.Anesthesiology
1988;69:a693)
40
35
30
25
%
Hct preop
HCTday 1
Hct day 2
20
15
10
5
0
haloth
predelivery
aloth pre& post
epidural
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
59. Conclusions for halog agents
and blood loss
Dose related decrease in uterine
contractility and tone
but no increase in blood loss if used in
low-moderate concentrations:
haloth 0.1-0.8
enflurane 0,5-1,5
isoflurane 0,75
sevoflurane…..
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
60. In every case,after delivery of
the neonate…...
Stop the volatile anesthetic
continue N2O(increase to 60-65%)
administer a IInd dose of hypnotic(TPS
100-150 mg;propofol 60-100 mg +
a potent analgesic:fentanyl 100-150
microgr..…
nmb if needed
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
61. Wojtczak, Jacek A., MD, PhD
The Hemodynamic Effects of Halothane and Isoflurane in
Chick Embryo Anesth Analg 2000; 90:1331
The cardiovascular effects of volatile anesthetics in
prenatal hearts are not well investigated. The purpose
of this study was to determine whether the embryonic
cardiovascular system is sensitive to an exposure to
clinically relevant, equipotent concentrations of
halothane and isoflurane. Stage 24 (4-day-old) chick
embryos were exposed to 0.09 and 0.16 mM of
halothane and 0.17 and 0.29 mM of isoflurane. Dorsal
aortic blood velocity was measured with a pulsedDoppler velocity meter. Halothane,
but not
isoflurane, caused a significant
decrease in cardiac stroke volume and
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
62. Effect of halothane on stroke volume and
acceleration of aortic blood in chick embryos
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
63. Effect of isoflurane on stroke volume and
acceleration of aortic blood in chick embryos
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
64. Biehl DR, Tweed A, Cote J, et al. Effect of halothane on
cardiac output and regional flow in the fetal lamb in utero.
Anesth Analg 1983; 62:489-92
We studied the effect of halothane on
the fetal cardiovascular system of six
lambs in utero by measuring fetal heart
rate and femoral arterial blood pressure
and by injecting labeled microspheres
during a control period and again after
60 and 90 min of halothane anesthesia
administered to six pregnant ewes at an
inspired concentration of 1.5%. There
were no significant effects on maternal
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
65. Biehl et al. Effect of halothane on cardiac
output and regional flow in the fetal lamb in
utero. Anesth Analg 1983; 62:489-92
Halothane 1.5%
30
20
10
% change from 0
control
-10
MAP
HR
heart BF
brain BF
-20
-30
-40
*
*
8
*
16
*
32
*
60
96
min
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
66. Bachman CR, Biehl DR, Sitar D, et al. Isoflurane potency and
cardiovascular effects during short exposure in foetal lamb.
Can Anesth Soc J 1986; 33:41-7
Isoflurane is a relatively new volatile
anaesthetic in clinical practice and
increasing use for obstetrical patients
might be expected. A previous study
demonstrated that a 60-90 minute
exposure of the foetus to isoflurane
resulted in a significant fall in foetal
cardiac output with development of
foetal acidosis. To determine the
cardiovascular effects Ospedale di Faenza(RA)
Servizio di Anestesia e Rianimazioneof a shorter
67. Baum VC, Palmisano BW. The immature heart and anesthesia.
Anesthesiology 1997; 87:1529-48
volatile anesthetics inhibit myocardial
function by depressing systems in
addition to ICa,L even in neonatal
myocardium. Baum and Wetzel showed
that halothane, in clinically relevant
concentrations, reversibly inhibits Na+—
Ca2+ exchange in neonatal ventricular
myocytes. This provides an additional
mechanism that may be responsible for
the more pronounced depression by
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
68. Baum VC, Palmisano BW. The immature heart and anesthesia.
Anesthesiology 1997; 87:1529-48
Halothane and isoflurane prolong AV
conduction time directly.
Anesthesia and O2 Consumption and
Metabolism
In vitro, halothane and isoflurane
increase coronary flow in a dose-related
manner in infant rabbit and fetal lamb
hearts. In the isolated heart preparation
in which coronary perfusion pressure is
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
69. Baum VC, Palmisano BW. The immature heart
and anesthesia. Anesthesiology 1997; 87:152948
In the neonatal lamb undergoing
hypoxic stress, neither halothane nor
isoflurane alter redistribution of blood to
vital organs, including the heart. In
addition, myocardial blood flow in the
neonatal lamb decreases significantly at
1 MAC isoflurane (from 250 to 88
ml×100 g-1×min-1), but in exact
proportion to Rianimazione Ospedale myocardial
the decrease in di Faenza(RA)
Servizio di Anestesia e
70. Baum VC, Palmisano BW. The immature heart
and anesthesia. Anesthesiology 1997; 87:152948
In neonatal rabbit hearts studied in vitro
with 1.5% halothane, McAuliffe and
Hickey found no change in steady-state
levels of high- energy phosphates or
intracellular pH, despite a 50%
decrement in mechanical performance.
Significant uncoupling of oxidative
phosphorylation cannot account for
halothane's depressant effect on
systolic function in the Ospedale di
Servizio di Anestesia e Rianimazione neonate.Faenza(RA)
71. Baum VC, Palmisano BW. The immature heart
and anesthesia. Anesthesiology 1997; 87:152948
Anesthesia and Systolic Function
The effects of the inhalational
anesthetics in intact immature hearts
have been evaluated in several studies.
Although one study suggested that the
apparent increase in hemodynamic
depression in the young heart in human
studies may be a result of differences in
anesthetic uptake and distribution, other
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
72. Baum VC, Palmisano BW. The immature heart
and anesthesia. Anesthesiology 1997; 87:152948
Summary
Immature hearts are more profoundly
affected by many anesthetics than are
adult hearts. Maturational changes in a
variety of cellular and subcellular
systems and influences of the
autonomic nervous system may be
responsible, but as yet, specific
mechanisms remain to be elucidated.
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
73. Brett CM, Teitel DF, Heymann MA, Rudolph AM: The young
lamb can increase cardiovascular performance during
isoflurane anesthesia. ANESTHESIOLOGY 71:751-6, 1989
Cardiac output and myocardial blood
flow decrease dramatically in a dosedependent pattern in the young lamb
during isoflurane anesthesia. This raises
important questions about the ability of
the young lamb to increase myocardial
performance if oxygen delivery were
compromised by a decrease in oxygen
content during anesthesia and surgery.
To investigate the ability of the young
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
74. Coagulation and anesthesia
The Effect of Anesthetic Techniques on
Blood Coagulability in Parturients as
Measured by Thromboelastography
Sharma, Shiv K., MD, FRCA; Philip,
John, MD
: Anesthetic techniques may affect
blood coagulability and the subsequent
incidence of thromboembolic events.
The purpose of this study was to
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
75. Interactions of volatile agents
with:
nifedipine;enhancement of
haemodynamic side effects with
aloth,enfl,iso(but non pregnant
animals…)..(and Rosone et
al..Hemodynamic responses to
nifedipine in dogs anesthetized with
halothane. Anesth.Analg 1983;62:903908.)
nicardipine enhancement of uterine
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
76. “Progesterone Decreases the MAC of
Desflurane in the Non Pregnant Ewe,”
was presented by Thompson and
collaborators, Ochsner Clinic, New
Orleans. They noted that the minimum
alveolar concentration for pregnant
ewes and that for nonpregnant ewes
treated with progesterone were similar.
The minimum alveolar concentration of
desflurane in untreated nonpregnant
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
77. Inhalational anesthetics with a rapid
equilibration between inspiratory and
end tidal concentraions,i.e less
soluble,should provide the correct
answer…..
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
78. the maternal and neonatal effects of
hsalothane,enflurane and isoflurane for cesarean
delivery.Anesth.Analg 1983;62:516-520.
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
79. Datta et al.Maternal and fetal catecholamines and uterine
incision-delivery interval during elective cesarean
section.Obstet.Gynecol 1990;75:600-603.
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
80. Neurobehavioral examination
Results more depressed(albeit subtle) in
neonates born from GA than reg….
(Shnider 238 pagg…)
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
81. Wallace DH et al.Randomized comparison of regional and
general anesthesia for cesarean delivery in pregnancies
complicated by severe preeclampsia.Obstet Gynecol
1995;86,193-
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
82. Gin T, Chan MTV: Decreased minimum alveolar
concentration of isoflurane in pregnant humans.
ANESTHESIOLOGY 81:829-32, 1994
<AB - BACKGROUND: Minimum
alveolar concentration (MAC) is
decreased in pregnant animals, but this
change has not been demonstrated in
humans, probably because of ethical
considerations. It is less problematic to
determine MAC in pregnant women
undergoing termination of pregnancy,
however, and therefore we compared
the MAC of e Rianimazione Ospedale di Faenza(RA)
Servizio di Anestesia isoflurane in these women
83. Chan M,Mainland P, Gin T
Minimum Alveolar Concentration of Halothane and
Enflurane Are Decreased in Early Pregnancy Anesthesiology
85:782-6, 1996
The MAC of halothane and enflurane
were compared in pregnant women
undergoing elective termination of
pregnancy and in nonpregnant women.
Methods: We studied 16 pregnant
women scheduled for termination of
pregnancy at 8 to 13 weeks gestation
and 16 nonpregnant patients
undergoing laparoscopic sterilization.
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
84. 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)
85. 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