This document discusses the management of various complications that can occur after spinal anesthesia. It covers: managing hypotension by using intravenous fluids, vasopressors like phenylephrine and ephedrine, treating post-dural puncture headache with conservative measures, caffeine, or epidural blood patch; managing shivering with warming measures and drugs like pethidine and tramadol; and treating accidental high spinal blockade by supporting vital functions and reversing positioning.
Obstetric Emergencies In Intensive Care Unit.pptAhmed Lotfy
-Peripartum cardiomyopathy
-Ovarian hyperstimulation syndrome
-Hypertension during pregnancy
-Respiratory failure during pregnancy
-Liver diseases and pregnancy
-CPR In Pregnancy
Hypertensive crisis in pregnancy by dr alka mukherjee dr apurva mukherjee nag...alka mukherjee
Hypertension affects 10% of pregnancies, many with underlying chronic hypertension, and approximately 1–2% will undergo a hypertensive crisis at some point during their lives. Hypertensive crisis includes hypertensive urgency and emergency; the American College of Obstetricians and Gynecologists describes a hypertensive emergency in pregnancy as persistent (lasting 15 min or more), acute-onset, severe hypertension, defined as systolic BP greater than 160 mmHg or diastolic BP >110 mmHg in the setting of pre-eclampsia or eclampsia. Pregnancy may be complicated by hypertensive crisis, with lower blood pressure threshold for end-organ damage than non-pregnant patients. Maternal assessment should include a thorough history. Fetal assessment should include heart rate tracing, ultrasound for growth and amniotic assessment, and Doppler evaluation if growth restriction is suspected. Initial management of hypertensive emergency (systolic BP >160 mmHg or diastolic BP >110 mmHg in the setting of pre-eclampsia or eclampsia) generally includes the rapid reduction of blood pressure through the use of intravenous antihypertensive medications, with goal systolic blood pressure between 140 mmHg and 150 mmHg and diastolic pressure between 90 mmHg and 100 mmHg. First-line intravenous drugs include labetalol and hydralazine, but other agents may be used, including esmolol, nicardipine, nifedipine, and, as a last resort, sodium nitroprusside. Among patients with hypertensive urgency, slower blood pressure reduction can be provided with oral agents. The objective of this article is to review the current understanding, diagnosis, and management of hypertensive crisis during pregnancy and the postpartum period.
Obstetric Emergencies In Intensive Care Unit.pptAhmed Lotfy
-Peripartum cardiomyopathy
-Ovarian hyperstimulation syndrome
-Hypertension during pregnancy
-Respiratory failure during pregnancy
-Liver diseases and pregnancy
-CPR In Pregnancy
Hypertensive crisis in pregnancy by dr alka mukherjee dr apurva mukherjee nag...alka mukherjee
Hypertension affects 10% of pregnancies, many with underlying chronic hypertension, and approximately 1–2% will undergo a hypertensive crisis at some point during their lives. Hypertensive crisis includes hypertensive urgency and emergency; the American College of Obstetricians and Gynecologists describes a hypertensive emergency in pregnancy as persistent (lasting 15 min or more), acute-onset, severe hypertension, defined as systolic BP greater than 160 mmHg or diastolic BP >110 mmHg in the setting of pre-eclampsia or eclampsia. Pregnancy may be complicated by hypertensive crisis, with lower blood pressure threshold for end-organ damage than non-pregnant patients. Maternal assessment should include a thorough history. Fetal assessment should include heart rate tracing, ultrasound for growth and amniotic assessment, and Doppler evaluation if growth restriction is suspected. Initial management of hypertensive emergency (systolic BP >160 mmHg or diastolic BP >110 mmHg in the setting of pre-eclampsia or eclampsia) generally includes the rapid reduction of blood pressure through the use of intravenous antihypertensive medications, with goal systolic blood pressure between 140 mmHg and 150 mmHg and diastolic pressure between 90 mmHg and 100 mmHg. First-line intravenous drugs include labetalol and hydralazine, but other agents may be used, including esmolol, nicardipine, nifedipine, and, as a last resort, sodium nitroprusside. Among patients with hypertensive urgency, slower blood pressure reduction can be provided with oral agents. The objective of this article is to review the current understanding, diagnosis, and management of hypertensive crisis during pregnancy and the postpartum period.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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
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!
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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
These lecture slides, by Dr Sidra Arshad, offer a quick overview of 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 leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
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. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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.
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.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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
2. Outline
• Management of hypotension after spinal block
• Management of PDPH
• Management of shivering after spinal
• Management of high /complete spinal
• Management of nausea & vomiting after spinal
3. Post spinal Hypotension:
Hypotension during induction of regional anaesthesia in
obstetric patients is associated with both maternal and fetal
morbidity.
The sympathectomy that occurs with neuraxial blockade
causes hypotension in women who receive spinal anaesthesia
for caesarean section.
Spinal hypotension can occur abruptly and may lead to
cardiovascular collapse. It causes maternal nausea and
vomiting and fetal acidosis
4. Hypotension caused by a reduction in SVR is normally
compensated by an increase in CO.
Under SA the increase in venous capacitance decrease CO,
because of veno -dilatation in the lower part of the body.
The situation is worsened in pregnancy by aortocaval
compression. Thus, more than 25%, CO usually decreases.
This is the combined effect of reduced cardiac output and
decreased SVR accounts for hypotension after spinal
anaesthesia.
5. The incidence => 80% ; the severity depends on the height
of the block, the position of the parturient, and whether
prophylactic measures were taken to prevent the hypotension.
Measures that decrease the risk of hypotension to varying
degrees include IV fluids, prevention of aorto-caval
compression, and monitoring of BP at frequent intervals after
placement of regional anesthetic.
6. General management
Large (16G) IV cannula (ensure adequate flow) prior to
neuraxial blockade
Establish baseline blood pressure
1 minute NIBP cycling post neuraxial blockade (until baby
delivered)
Apply wedge for left lateral tilt, consider full left lateral/asking
surgeon to lift the uterus if refractory hypotension
7. Management con…
Maintain SPB above 100 mmHg or >80% of pre-regional
blood pressure.
Bradycardia (HR<60 should be treated with atropine, if
accompanied with hypotension.
Do not use ephedrine before the baby is born.
Monitor blood loss to ensure that absolute hypovolemia does
not contribute to hypotension
Do not treat hypovolemia (eg hemorrhage) with vasopressors
8. Intravenous administration:
Crystalloid pre-loading has been shown to be clinically
ineffective at preventing hypotension.
Rapid crystalloid administration after induction of spinal
anaesthesia (coloading) provides better maternal blood
pressure control than pre-loading (Dyer et al. 2004)
but should be combined with the use of vasopressors to
prevent hypotension.
9. Crystalloid vs colloid
A recent systematic review found that crystalloid was
inconsistent in preventing hypotension and that colloid was
significantly better.
Dahlgren et al studied crystalloid compared with colloid for
preloading. Hypotension was significantly reduced after larger
volumes of colloid.
10. In another study of preloading comparing pentastarch with
crystalloid, French et al demonstrated a reduction in the
incidence of hypotension in the colloid group (12.5% versus
47.5%).
In contrast to these studies which all found colloid preload of
benefit, Karinen et al failed to find any reduction in the
incidence of hypotension when colloid was used
11. • Several recent studies have compared prehydration versus
cohydration both with crystalloids and colloids and shown that
haemodynamic changes and vasopressor requirement are
similar.
• Meta analysis (eight studies, 518 parturients),they found that
the incidence of hypotension to be similar for cohydration to
that of prehydration.
12. VASOPRESSORS
Ephedrine has been the drug of choice for more than 30 years in the
treatment of maternal hypotension in obstetric spinal anesthesia when
conservative measures fail.
Sympthomimetic with mixed effect.
Ephedrine has a slow onset of action making it difficult to
titrate and use it with an appropriate bolus dose.
As proved by various studies, a single prophylactic dose is
ineffective and the effectiveness depends on variable doses and
the rate of administration
13. Ephedrine depresses fetal PH more than Phenylephrine
– Ngan Knee et al demonstrated that ephedrine crosses placenta
more readily than phenylephrine.
Phenylephrine is a short-acting, potent, vasoconstrictor
that causes an increase in both systolic and diastolic blood
pressure.
– It counteracts the vasodilatation due to neuraxial anaesthesia
directly, restoring baseline blood pressure.
Traditionally, it was used as a second line vasoconstrictor
in obstetrics because of the concerns that it caused
vasoconstriction in the uteroplacental circulation.
14. When compared to ephedrine it has been shown to be:
- Easier to titrate
- Faster onset
- More effective at increasing systemic vascular resistance
- Causes less maternal tachycardia and hypertension
- Associated with improved fetal pH (Ngan Kee et al. 2003)
15. Phenylephrine can be administered by bolus or infusion.
A prophylactic bolus has been shown to be superior to a
therapeutic bolus with regards to incidence of hypotension,
NV(Das Neves et al. 2010).
Metaraminol:- a mixed alpha and beta agonist can be used for
spinal induced hypotension.
– Ngan Kee and colleagues demonstrated that Metaraminol was superior
to ephedrine at maintaining both maternal blood pressure and fetal pH
during spinal anesthesia for caesarean section.
16. PDPH
• Post-partum headache is the complaint of headache and neck
or shoulder pain in the first 6 weeks after delivery.
• Up to 39% of parturients experience headache in the first
postpartum week.
• Not all postpartum headache is PDPH, and as anaesthetists are
asked to review patients often, it is important to be aware of
the differential diagnoses
17. PDPH
• In parturients, the collective risk of unintentional dural
puncture with an epidural needle is ~1.5%, and of these,
52.1% will experience PDPH.
• After spinal injection, the incidence of headache ranges from
1.5 to 11.2%, depending on the size and type of needle.
18. PATHOGENESIS
CSF leakage into the epidural space via a tear in the dura.
CSF loss leads to a reduction in intracranial pressure and
downward traction on pain-sensitive intracranial
structures(veins, meninges and cranial nerves) resulting in a
headache that is classically worse in the upright position.
The fall in intracranial pressure may also cause
compensatory cerebro-vascular venodilation and this may
contribute to the development of the headache.
19. DIAGNOSIS AND DIFFERENTIAL
DIAGNOSIS
The fundamental principle in the assessment of any parturient with a
post-partum headache is to carefully consider the differential
diagnosis.
Infective: Meningitis, Encephalitis
Pharmacological/Metabolic:
Dehydration and Caffeine withdrawal
Vascular: Migraine, Cerebral vein thrombosis, Cerebral
infarction, Subdural haematoma & Subarachnoid haematoma
20. A history and examination should be performed taking account
of the timing of the headache in relation to the neuraxial
procedure, the nature of the headache as well as other
symptoms and signs.
In the case of a headache following a spinal procedure, PDPH
is more likely following dural puncture with a larger gauge
‘cutting’ tipped needle or after multiple attempts,
increasing the chance of a CSF leak.
21. Classic features of the headache caused by dural puncture:
Headache is often frontal-occipital.
Most headaches do not develop immediately after dural
puncture but 24-48 hours after the procedure with 90% of
headaches presenting within 3 days.
The headache is worse in the upright position and eases when
supine.
Pressure over the abdomen with the woman in the upright
position may give transient relief to the headache by raising
intracranial pressure secondary to a rise in intra-abdominal
pressure(Gutsche’s test).
22. Associated symptoms: neck stiffness, photophobia, tinnitus,
visual disturbance and cranial nerve palsies.
MRI may demonstrate diffuse dural enhancement and brain
descent.
23. MANAGEMENT
Conservative Management: Most post-dural puncture
headache will resolve spontaneously.
Conservative management has traditionally involved bed rest
and fluids though there is little evidence to support either of
these measures.
A recent Cochrane review concluded that routine bed rest after
dural puncture is not beneficial and should be abandoned.
While routine administration of additional fluids may be
unnecessary, avoidance of dehydration is advisable to help
limit headache severity. => traditional, lack evidence
24. Pharmacological
Many drugs have been recommended to treat PDPH, however
in the vast majority of cases, evidence of effectiveness is
limited.
Simple analgesia should be instituted in all patients with
PDPH; regular paracetamol and non-steroidal anti-
inflammatory medications may control symptoms adequately.
25. Caffeine:
Caffeine was first reported as a treatment for PDPH in 1949.
Caffeine is a central nervous system stimulant and is thought
to influence PDPH by inducing cerebral vasoconstriction.
Doses from 75 – 500 mg have been investigated and caffeine
has been administered orally, intramuscularly and
intravenously.
Caffeine is associated with adverse events including cardiac
arrhythmias and maternal seizures. In high doses (probably
>300mg) caffeine may enter breast milk and potentially lead to
neonatal irritability.
26. Many randomized trials failed to show superiority of caffeine
over other conservative methods to treat PDPH.
More recently, a randomized, double-blinded, placebo
controlled trial by Ragab and Facharzt in 2014 comparing
intravenous caffeine with placebo shows that IV caffeine can
be effective in reducing the rate and severity of PDPH.
– It may be that intravenous caffeine is effective while oral
caffeine is not.
27. Other conservative therapies being studied that have
also showed promising results.
A prospective, randomized, double-blinded, placebo-
controlled trial in which epidural morphine was
administered as 2- 3 mg dose 24 hours apart reduced
the incidence of PDPH from 48% to 12%
28. Invasive Management
• Epidural blood patch (EBP) after observation that patients
blood spinal tap at lumbar puncture were less likely to develop
PDPH.
• the first epidural blood patch was performed in 1960 by the
American surgeon, Dr James Gormley.
• Just 2 ml of the patient’s blood was injected during the first
epidural blood patch and the headache was relieved.
29. Epidural blood patching involves injection of autologous blood
into the epidural space.
It remains one of the few proven treatments of PDPH however
the mechanism of action remains unclear.
The resulting blood clot may have a “patch effect” on the dural
tear while the volume of blood transfused into the epidural
space raises intracranial pressure and reduces ongoing CSF
leak.
30. Effectiveness:
Early studies of the efficacy of EBP (up to 90%)
Permanent cure by a single blood patch can be expected
in 50% of patients.
About 40% of patients require a second blood patch
Despite the falling success rates, EBP remains the most
effective treatment for PDPH and has been shown in a
randomized controlled trial to be more effective than
conservative treatment in treating established PDPH.
31. Optimal Technique
EBP should be performed by two personnel, one an
experienced anaesthetist, the other competent in taking a
volume of blood from the arm. Both should employ full
aseptic precautions.
Contraindications to EBP include:
- Sepsis,
- Coagulopathy and
- Patient refusal.
32. EBP is likely to be most effective if performed at least 24
hours after the onset of PDPH.
Volumes of between 20-60mls of blood have been used.
Optimal volume is unknown but current recommendations
suggest 10 to 20ml should be injected
33. If the patient reports discomfort in the back during the
procedure the injection should be stopped.
The patient should lie flat for 1-2 hours after the procedure.
There is no evidence that bed rest for longer than this time is
beneficial.
Once discharged from hospital, follow up by telephone over
the first few days after EBP and review at 6 weeks is
recommended
34. Shivering:
Post-anesthetic shivering is spontaneous, involuntary ,
rhythmic , oscillating, tremor-like muscle hyperactivity that
increases metabolic heat production after general or regional
anesthesia.
The probable mechanisms could be decrease in core body
temperature secondary to:
– sympathetic block;
– peripheral vasodilatation;
– Increased cutaneous blood flow, which leads to increased heat loss
through skin;
– cold temperature of operation theatre; rapid infusion of cold IV fluids;
and effect of cold anaesthetic drugs upon the thermo sensitive receptors
in the spinal cord
36. Non-pharmacological methods:
A number of physico-chemical methods helpful to prevent
PAS
There are three basic strategies for the prevention and
treatment of hypothermia and shivering:
(i) minimising redistribution of heat;
(ii) cutaneous warming during anaesthesia: Passive insulation/Active
warming
(iii) internal warming.
Minimising redistribution of heat
This can be achieved by preoperative warming of peripheral tissues
It minimise phase I hypothermia
this would require subjecting patients to over 1 h of exposure to a
source of radiated heat pre-operatively
37. Cutaneous warming during anaesthesia
1. Passive insulation
2. Active warming
Internal warming
38. Review of literatures
9 RCTs for pethedine
4 RCT for tramadol, doxapram, and clonidine;
2 RCTs for nalbuphin
Evidence for these 5 drugs was found to be sufficient and
statistically significant.
39. Pethidine for treatment of PAS
Research has provided abundant documentation regarding
pethidine’s potent anti-shivering effects
However, the mechanism for these effects is poorly understood
This drug exerts its action on ĸ-opioid receptors (KOR) and μ-
opioid receptors (MOR),
– Researchers developed the theory that meperidine’s action on KOR
mediates its effect on PAS.
40. Tramadol
A synthetic and centrally acting opioid
MOA:
• activating MORs and blocking norepinephrine and
serotonin reuptake
– 5 HT caused shivering and vasoconstriction
– Norepinephrine lowered the normal resting
temperature and attenuated the 5 HT induced
hyperthermia.
– The balance b/n 5 HT & norepinephrine inputs may
be responsible for thermoregulatory response.
41. Tramadol versus Pethidine
All studies, whether RCTs or systematic reviews, found
tramadol as effective as meperidine
However, researchers considered tramadol qualitatively
superior than pethidine due to:
• a faster onset
• Easily available
• no recurrence of shivering,
• shorter duration of recovery, and fewer adverse effects
• Three RCTs reported that tramadol 0.5 to 1 mg/kg was
effective
42. Clonidine
An alpha 2 adrenergic receptors agonist
It is effective at 0.15mg dose to treat PAS
MOA
The hypothalamus, where alpha 2 receptors are found, is
responsible for controlling body temperature.
thought to work on hypothalamic receptors to inhibit
vasoconstriction and shivering or
at other CNS levels by altering incoming thermal
information
43. Magnesium sulphate and ketamine
• competitive antagonist at NMDA-receptors and was found to
stop post-anaesthetic shivering
44. Management of accidental high spinal blockade
Complete spinal block is caused by local anaesthetic
interfering with the normal neuronal function in the cervical
spinal cord and brain stem.
RISK FACTORS:
Drug factors
–dose
-Baricity
-Prior drug administration
Patient factors –
-body morphology
-Anatomical or pathological factors
45. Technique factors
1. Higher lumbar insertion may increase final block height
2. Position at and following injection – sitting may minimize
cephalad spread
3. Spinal needle – finer gauge and cephalad direction of needle
hole may increase risk of higher block
46. MANAGEMENT
Management is supportive and dependent on degree
and height of block.
Early recognition is vital as block progression may
be mitigated (reverse trendelenberg/head raised) or
serious cardio-respiratory compromise avoided.
47. Management:
FEATURE MANAGEMENT
Bradycardia Vagolytics eg. atropine
Hypotension Sympathomimetics eg.
ephedrine, adrenaline
Vasopressors eg. metaraminol,
phenylephrine Fluid boluses
Leg elevation
Respiratory dysfunction Oxygenation Intubation and
ventilation
Loss of consciousness Secure airway , supportive
measures
49. Mechanisms of Postoperative Nausea and Vomiting in
Regional Anesthesia
Several different mechanisms may play a role in causing
PONV in patients who receive regional anesthesia.
In a retrospective analysis, Crocker and Vandam found that
hypotension (systolic blood pressure <80 mmHg), a block
higher than T5.
50. Management:
• Phenothiazines:
Promethazine, prochlorperazine, and chlorpromazine are all
phenothiazines, exert their antiemetic effects by directly acting
on the central dopaminergic receptors of the chemoreceptor
trigger zone .
These agents are most effective in the treatment of opioid
induced PONV, but their use as the primary treatment for
PONV is limited by their tendency to cause sedation.
51. Butyrophenone
Droperidol is the only butyrophenone currently used in the
treatment of PONV.
Like the phenothiazines, droperidol acts competitively on
central dopaminergic receptors and is associated with sedation,
lethargy, agitation and extraphyramidal effects,
52. Antihistamines
Diphenhydramine, hydroxyzine, Vistaril®, and cyclizine
are all antihistamines which work to prevent nausea and
vomiting by acting on the H1 receptors.
Using as postoperative agents is limited by the excessive
sedation associated with administration.
53. Anticholinergic
Scopolamine is an anticholinergic agent that acts on the
muscarinic and histaminic receptors of the vestibular apparatus
used to reduce the incidence of PONV.
Very effective in patients treated with opioids ,
Complications: use is limited by a high incidence of sedation,
dry-mouth, dysphoria, confusion, disorientation, visual
disturbances and hallucinations.
54. Benzamides
Metoclopramide and trimethobenzamide are benzamides
– act on both central dopamine and serotonin receptors, with
both prokinetic and antiemetic effects.
Metoclopramide increases gastrointestinal tract motility,
decreasing gastric emptying time and gastric volume, and is
usually well tolerated in adult patients.
55. Serotonin antagonists
Ondansetron, granisetron, dolasetron, tropisetron and other
serotonin antagonists have been shown to provide effective
treatment and prophylaxis of PONV and are associated with a
low incidence of mild side effects.
– They are not dopamine, muscarinic or histamine receptor antagonists.
Others
Anxiolytics-Midazolam
Steroids=> Dexamethasone
Phenylephrine is now the vasopressor of choice in obstetrics.
This drug is finding favour in the eyes of researchers worldwide when compared to meperidine
a. Block height more dependent on dose than volume (higher dose gives higher risk)
b. Baricity – cephalad spread easier to control with hyperbaric solution
Body morphology – higher BMI or abdominal girth (including pregnancy) may reduce thecal volume and increase the risk of high block
Anatomical or pathological factors – compressed thecal sack (epidural fluid & dilated vessels), spinal canal abnormality can give higher risk
c. Prior drug administration – such as epidural local anaesthetic diffusion (unrecognised/sub-clinical block gives higher risk)