José Aristeu Fachini Frias

Spinal anesthesia for cesarean section. Use of hyperbaric bupivacaine (10mg) combined with different adjuvants.

BACKGROUND AND OBJECTIVES Combination of local anesthetics (LA) with adjuvants for spinal anesthesia improves block quality and prolongs the duration of analgesia. It was evaluated the maternal effects and neonatal repercussions of sufentanil, morphine, and clonidine combined with hyperbaric bupivacaine for elective cesarean section. METHOD Prospective, randomized, blinded study of 96 patients allocated into four groups: Group I (no adjuvant), Group II (sufentanil 5.0 μg), Group III (morphine 100 μg), and Group IV (clonidine 75 μg). It was evaluated the onset and level of sensory block, perioperative analgesia, degree and recovery time of motor block, duration of analgesia, sedation, and maternal-fetal repercussions. RESULTS The onset of blockade was significantly faster in groups with adjuvants compared with Group I. Patients in Groups I and III reported pain during the perioperative period. Duration of analgesia was significantly higher in Group II and time to motor block recovery was significantly higher in Group IV. Pruritus occurred in Groups II and III. Sedation was significant in Group IV and there was prolonged arterial hypotension in Group IV. CONCLUSION Addition of sufentanil and clonidine to hyperbaric bupivacaine provided adequate anesthesia for cesarean section and good postoperative analgesia. Clonidine caused more perioperative sedation and longer time to motor block recovery. Pruritus was evident when opioids were used.

Spinal anesthesia for elective ceasarean section: use of different doses of hyperbaric bupivacaine associated with morphine and clonidine

PURPOSE To comparatively study the efficacy and maternal and fetal side-effects of two doses of bupivacaine associated with morphine and clonidine, administered by the subarachnoid route for cesarean section. METHODS The study included 66 pregnant women at term, distributed into two groups. GI: bupivacaine 8.0 mg (1.6 mL) + clonidine 75 µg (0.5 mL) + morphine 100 µg (1.0 mL) and GII: bupivacaine 10 mg (2.0 mL) + clonidine 75 µg (0.5 mL) + morphine 100 µg (1.0 mL). The following parameters were assessed: onset and maximum level of sensory block; quality of intraoperative and postoperative analgesia; degree and duration of motor block; maternal repercussions and Apgar score. RESULTS The onset of sensory block, quality of intraoperative analgesia and total duration of analgesia were similar in both groups; maximum extent of sensory block predominated in T4; maximum degree of motor block (Bromage 3); time motor block regression was significantly longer in GII; Hemodynamic, respiratory repercussions, adverse maternal effects and Apgar scores were similar between groups. In both groups, there was a predominance of drowsy or sleeping patients. CONCLUSION The addition of morphine and clonidine to low doses of hyperbaric bupivacaine produced adequate anesthesia for cesarean section and good postoperative analgesia, without any maternal and fetal repercussions.

Spinal Block with 10 mg of Hyperbaric Bupivacaine Associated with 5 μg of Sufentanil For Cesarean Section. Study of Different Volumes

BACKGROUND AND OBJECTIVES Several factors affect the cephalad dispersion of the anesthetic solution in the subarachnoid space; among them, physiological changes of pregnancy and the dose and volume of the local anesthetics should be mentioned. The objective of this study was to assess the effectivity and side effects of different volumes of the subarachnoid administration of the association of hyperbaric bupivacaine and sufentanil in cesarean sections. METHODS Forty patients, ASA I and II, undergoing elective cesarean section under spinal block were divided in two groups, according to the volume of the anesthetic solution: Group I (4 mL) and Group II (3 mL). The association of hyperbaric bupivacaine (10 mg(2) mL) and sufentanil (5 microg-1 mL) was used in both groups. In Group I, 1 mL of NS was added to the solution to achieve the volume of 4 mL. The following parameters were evaluated: latency of the blockade; upper limit of the sensorial blockade; degree of motor blockade; time for regression of the motor blockade; total duration of analgesia; maternal side effects; and neonatal repercussions. RESULTS Latency, the upper limit of the sensorial blockade, and the degree and time for regression of the motor blockade were similar in both groups; duration of analgesia was greater in Group I than in Group II, which was statistically significant. The incidence of side effects was similar in both groups. Maternal cardiocirculatory changes and neonatal repercussions were not observed. CONCLUSIONS Four milliliter of anesthetic solution composed of hyperbaric bupivacaine, 10 mg, associated with 5 microg of sufentanil was more effective than 3 ml of the same solution, providing better intra-and postoperative analgesia without maternal-fetal repercussions.

Anestesia espinhal com 10 mg de bupivacaína hiperbárica associada a 5 µg de sufentanil para cesariana: estudo de diferentes volumes

JUSTIFICATIVA Y OBJETIVOS: Diversos factores influyen en la dispersion cefalica de la solucion anestesica en el espacio subaracnoideo, entre los cuales se destacan las alteraciones fisiologicas inherentes al embarazo, baricidad, dosis y volumen del anestesico local. El objetivo de este estudio fue evaluar la efectividad y los efectos colaterales de diferentes volumenes de la asociacion de bupivacaina hiperbarica y sufentanil por via subaracnoidea en cesareas. METODO: Cuarenta pacientes, ASA I y II, sometidos a cesarea electiva bajo raquianestesia distribuidos en dos grupos, de acuerdo con el volumen de la solucion anestesica usada: Grupo I (4 mL) y Grupo II (3 mL). En los dos grupos, el anestesico local empleado fue la bupivacaina hiperbarica (10 mg-2 mL) asociada al sufentanil (5 µg-1 mL). En el Grupo I, para la obtencion del volumen de 4 mL, se anadio 1 mL de solucion fisiologica a 0,9%. Se evaluaron: latencia del bloqueo; nivel maximo del bloqueo sensitivo; grado del bloqueo motor; tiempo para regresion del bloqueo motor; duracion total de la analgesia; efectos adversos maternos y repercusiones neonatales. RESULTADOS: La latencia, el nivel maximo del bloqueo sensitivo, el grado y el tiempo para la regresion del bloqueo motor fueron similares en los dos grupos; la duracion de la analgesia fue mayor en el Grupo I, con una diferencia significativa con relacion al Grupo II. Los efectos adversos se dieron a menudo de forma similar en los dos grupos. Se registro la ausencia de las alteraciones cardiocirculatorias maternas y de las repercusiones neonatales. CONCLUSIONES: La bupivacaina hiperbarica en dosis de 10 mg asociada al sufentanil en dosis de 5 µg, con un volumen de 4 mL, fue mas eficaz que la misma asociacion en un menor volumen (3 mL), proporcionando una mejor analgesia intra y postoperatoria, sin repercusiones materno-fetales.

Association of lipophilic opioids and hyperbaric bupivacaine in spinal anesthesia for elective cesarean section. Randomized controlled study

PURPOSE To evaluate the efficacy and side-effects of fentanyl and sufentanil combined with hyperbaric spinal bupivacaine in elective cesarean section. METHODS A prospective, randomized, double-blind study with 64 term parturients, distributed into 2 groups according to the opioid combined with hyperbaric bupivacaine 0.5% (10mg): GF - fentanyl (25 µg) and GS - sufentanil (5.0 µg). The latency and maximum sensory block level; degree and duration of motor block; duration and quality of analgesia; maternal-fetal repercussions were evaluated. This was an intention-to-treat analysis with a 5% significance level. RESULTS The latency period, maximum sensory block level, motor block degree and perioperative analgesia were similar in both groups. Motor block and analgesia had a longer duration in the sufentanil group. Maternal adverse effects and neonatal repercussions were similar. The incidence of hypotension was higher in the fentanyl group. In both groups, there was a predominance of patients who were awake and either calm or sleepy. CONCLUSIONS The addition of fentanyl and sufentanil to hyperbaric subarachnoid bupivacaine was shown to be effective for the performance of cesarean section, and safe for the mother and fetus. Analgesia was more prolonged with sufentanil.

Epidural block for cesarean section: a comparative study between 0.5% racemic Bupivacaine (S50-R50) and 0.5% enantiomeric excess Bupivacaine (S75-R25) associated with Sufentanil

BACKGROUND AND OBJECTIVES Epidural 0.5% racemic bupivacaine associated with opioids is a technique used in cesarean sections; however, its toxicity has been questioned. 50% Enantiomeric excess bupivacaine has lower cardio- and neurotoxicity. The efficacy of epidural 0.5% racemic bupivacaine and 0.5% enantiomeric excess bupivacaine associated with sufentanil in parturients undergoing cesarean sections was evaluated. METHODS Fifty gravida at term, undergoing elective cesarean section under epidural block, were divided in two groups according to the local anesthetic used: Group I - 0.5% racemic bupivacaine with vasoconstrictor; and Group II - 0.5% enantiomeric excess bupivacaine (S75-R25) with vasoconstrictor. In both groups, the local anesthetic (100 mg) was associated with sufentanil (20 microg), and a total of 24 mL of the solution was used. The following parameters were evaluated: latency of the sensitive blockade; maximal level of the sensitive blockade; degree for motor blockade; time of motor blockade regression; duration of analgesia; maternal side effects; and neonatal repercussions. RESULTS Latency, maximal level of sensitive blockade, degree of motor blockade, and duration of analgesia were similar in both groups; the mean time for regression of the motor blockade was significantly smaller in Group II. The incidence of side effects was similar in both groups. Maternal cardiocirculatory changes and neonatal repercussions were not observed. CONCLUSIONS Epidural racemic bupivacaine and 50% enantiomeric excess bupivacaine provided adequate anesthesia for cesarean sections. 50% Enantiomeric excess bupivacaine is a promising alternative for this procedure, since it has faster regression of the motor blockade, which is desirable in obstetric patients.

Anestesia para tratamento intraparto extra-útero em feto com diagnóstico pré-natal de higroma na região cervical: relato de caso

BACKGROUND AND OBJECTIVES Ex utero intrapartum treatment (EXIT) is a procedure performed during Cesarean section with preservation of fetal-placental circulation, which allows the safe handling of fetal airways with risk of airways obstruction. This report aimed at describing a case of anesthesia for EXIT in a fetus with cervical cystic hygroma. CASE REPORT Female patient, 22 years old, 37 weeks gestation without anesthetic background, physical status ASA I, submitted to EXIT for airway handling and tracheal intubation of fetus at risk for airway obstruction. Procedure was performed under general anesthesia associated to continuous epidural anesthesia. Patient was premedicated with intravenous metoclopramide (10 mg) and ranitidine (50 mg). Epidural 0.25% bupivacaine with epinephrine (30 mg) associated to fentanyl (100 mg) was administered, followed by cephalic catheter for postoperative analgesia. Uterus was displaced to the left. Anesthesia was induced in rapid sequence with fentanyl, propofol and rocuronium and was maintained with isoflurane in 2.5 at 3% in O2 and N2O (50%). After hysterotomy, fetus was partially released assuring uterus-placental circulation, followed by fetal laryngoscopy and tracheal intubation. Then fetus was totally released with umbilical cord clamping, administration of oxytocin (20 UI) in continuous infusion, followed by intravenous methyl-ergonovine (0.2 mg). Maternal systolic pressure was maintained above 100 mmHg during the procedure with bolus ephedrine (5 mg) and crystalloids (3000 mL). Isoflurane concentration was gradually decreased during uterine closure. At surgery completion neuromuscular block was reversed and morphine (2 mg) was injected through the epidural catheter for postoperative analgesia. CONCLUSIONS Major recommendations for EXIT are maternal-fetal safety, uterine relaxation to maintain uterine volume and uterus-placental circulation, and fetal immobility to help airway handling.JUSTIFICATIVA Y OBJETIVOS: El tratamiento intraparto extrautero (EXIT) constituye un procedimiento realizado durante la cesaria, con preservacion de la circulacion feto-placentaria, que permite el manejo seguro de la via aerea del feto, con riesgo de obstruccion de las vias aereas. El objetivo de este relato fue el de presentar un caso de anestesia para EXIT, en feto con higroma cistico en la region cervical. RELATO DEL CASO: Paciente con 22 anos, 37 semanas de gestacion, sin antecedentes anestesicos, estado fisico ASA I, sometida a EXIT para manejo de via aerea e intubacion traqueal en feto con riesgo para obstruccion de vias aereas. El procedimiento se realizo bajo anestesia general asociada a peridural continua. En el preoperatorio fueron utilizados metoclopramida (10 mg) y ranitidina (50 mg), por via venosa. En el espacio peridural se administro bupivacaina a 0,25% con adrenalina (30 mg) asociada a fentanil (100 µg), seguida de la introduccion de cateter cefalico, para analgesia postoperatoria. El utero fue desplazado para la izquierda. La induccion anestesica se hizo en secuencia rapida, con fentanil, propofol y rocuronio y el mantenimiento con isoflurano en 2,5% a 3%, en O2 y N2O (50%). Despues de la histerotomia, se procedio a la liberacion parcial del feto, asegurando la circulacion utero placentaria, siguiendo las maniobras de laringoscopia e intubacion traqueal fetal. A continuacion se realizo la liberacion total del feto, con pinzamiento del cordon umbilical, administracion de ocitocina (20 UI) en infusion venosa continua seguida de metil-ergonovina (0,2 mg) por via venosa. Durante el procedimiento, la presion arterial sistolica materna se mantuvo por encima de 100 mmHg, con efedrina en bolus (5 mg) y cristaloide (3000 mL). La concentracion del isoflurano disminuyo gradualmente durante el cierre uterino. Al final de la intervencion quirurgica el bloqueo neuromuscular fue revertido y se inyecto morfina (2 mg) por el cateter peridural para analgesia posoperatoria. CONCLUSIONES: Las principales recomendaciones para la realizacion del EXIT son seguridad materno-fetal, relajamiento uterino para el mantenimiento del volumen uterino y de la circulacion utero placentaria y el no movimiento fetal para facilitar el manejo de las vias aereas.

Anesthesia for ex utero intrapartum treatment of fetus with prenatal diagnosis of cervical hygroma: case report

BACKGROUND AND OBJECTIVES Ex utero intrapartum treatment (EXIT) is a procedure performed during Cesarean section with preservation of fetal-placental circulation, which allows the safe handling of fetal airways with risk of airways obstruction. This report aimed at describing a case of anesthesia for EXIT in a fetus with cervical cystic hygroma. CASE REPORT Female patient, 22 years old, 37 weeks gestation without anesthetic background, physical status ASA I, submitted to EXIT for airway handling and tracheal intubation of fetus at risk for airway obstruction. Procedure was performed under general anesthesia associated to continuous epidural anesthesia. Patient was premedicated with intravenous metoclopramide (10 mg) and ranitidine (50 mg). Epidural 0.25% bupivacaine with epinephrine (30 mg) associated to fentanyl (100 mg) was administered, followed by cephalic catheter for postoperative analgesia. Uterus was displaced to the left. Anesthesia was induced in rapid sequence with fentanyl, propofol and rocuronium and was maintained with isoflurane in 2.5 at 3% in O2 and N2O (50%). After hysterotomy, fetus was partially released assuring uterus-placental circulation, followed by fetal laryngoscopy and tracheal intubation. Then fetus was totally released with umbilical cord clamping, administration of oxytocin (20 UI) in continuous infusion, followed by intravenous methyl-ergonovine (0.2 mg). Maternal systolic pressure was maintained above 100 mmHg during the procedure with bolus ephedrine (5 mg) and crystalloids (3000 mL). Isoflurane concentration was gradually decreased during uterine closure. At surgery completion neuromuscular block was reversed and morphine (2 mg) was injected through the epidural catheter for postoperative analgesia. CONCLUSIONS Major recommendations for EXIT are maternal-fetal safety, uterine relaxation to maintain uterine volume and uterus-placental circulation, and fetal immobility to help airway handling.JUSTIFICATIVA Y OBJETIVOS: El tratamiento intraparto extrautero (EXIT) constituye un procedimiento realizado durante la cesaria, con preservacion de la circulacion feto-placentaria, que permite el manejo seguro de la via aerea del feto, con riesgo de obstruccion de las vias aereas. El objetivo de este relato fue el de presentar un caso de anestesia para EXIT, en feto con higroma cistico en la region cervical. RELATO DEL CASO: Paciente con 22 anos, 37 semanas de gestacion, sin antecedentes anestesicos, estado fisico ASA I, sometida a EXIT para manejo de via aerea e intubacion traqueal en feto con riesgo para obstruccion de vias aereas. El procedimiento se realizo bajo anestesia general asociada a peridural continua. En el preoperatorio fueron utilizados metoclopramida (10 mg) y ranitidina (50 mg), por via venosa. En el espacio peridural se administro bupivacaina a 0,25% con adrenalina (30 mg) asociada a fentanil (100 µg), seguida de la introduccion de cateter cefalico, para analgesia postoperatoria. El utero fue desplazado para la izquierda. La induccion anestesica se hizo en secuencia rapida, con fentanil, propofol y rocuronio y el mantenimiento con isoflurano en 2,5% a 3%, en O2 y N2O (50%). Despues de la histerotomia, se procedio a la liberacion parcial del feto, asegurando la circulacion utero placentaria, siguiendo las maniobras de laringoscopia e intubacion traqueal fetal. A continuacion se realizo la liberacion total del feto, con pinzamiento del cordon umbilical, administracion de ocitocina (20 UI) en infusion venosa continua seguida de metil-ergonovina (0,2 mg) por via venosa. Durante el procedimiento, la presion arterial sistolica materna se mantuvo por encima de 100 mmHg, con efedrina en bolus (5 mg) y cristaloide (3000 mL). La concentracion del isoflurano disminuyo gradualmente durante el cierre uterino. Al final de la intervencion quirurgica el bloqueo neuromuscular fue revertido y se inyecto morfina (2 mg) por el cateter peridural para analgesia posoperatoria. CONCLUSIONES: Las principales recomendaciones para la realizacion del EXIT son seguridad materno-fetal, relajamiento uterino para el mantenimiento del volumen uterino y de la circulacion utero placentaria y el no movimiento fetal para facilitar el manejo de las vias aereas.

Influence of Hypnotics on Cisatracurium-induced Neuromuscular Block. Use of Acceleromyograhpy

BACKGROUND AND OBJECTIVE Different drugs, including hypnotics, may influence the pharmacodynamic effects of neuromuscular blockers (NMB). The aim of this study was to evaluate the influence of propofol and etomidate on cisatracurium-induced neuromuscular blockade. METHOD We included 60 patients, ASA I and II, undergoing elective surgery under general anesthesia in the study and randomly allocated them into two groups, according to their hypnotic drug: GI (propofol) and GII (etomidate). Patients received intramuscular (IM) midazolam (0.1mg.kg(-1)) as premedication and we performed induction with propofol (2.5mg.kg(-1)) or etomidate (0.3mg.kg(1)), preceded by fentanyl (250mg) and followed by cisatracurium (0.1mg.kg(-1)). The patients were ventilated with 100% oxygen until obtaining a reduction of 95% or more in the adductor pollicis response amplitude, with subsequent laryngoscopy and tracheal intubation. Neuromuscular function was monitored by acceleromyograhpy. We evaluated the onset of action of cisatracurium, tracheal intubation conditions, and hemodynamic repercussions. RESULTS The mean time and standard deviations of cisatracurium onset were: GI (86.6±14.3s) and GII (116.9±11.6s), with a significant difference (p<0, 0001). Intubation conditions were acceptable in 100% of GI and 53.3% of GII patients (p<0.0001). CONCLUSION Induction of neuromuscular blockade with cisatracurium was faster, with better intubation conditions in patients receiving propofol compared to those receiving etomidate, without hemodynamic repercussions.

Raquianestesia em operação cesariana. Emprego da associação de bupivacaína hiperbárica (10 mg) a diferentes adjuvantes

JUSTIFICATIVA Y OBJETIVOS: La asociacion de anestesicos locales (AL) a adyuvantes por via subaracnoidea mejora la calidad del bloqueo y prolonga la duracion de la analgesia. Se evaluaron los efectos maternos y las repercusiones neonatales de la asociacion de sufentanil, morfina y clonidina a la bupivacaina hiperbarica en la cesarea electiva. METODO: Estudio prospectivo, randomizado, encubierto, con 96 pacientes distribuidas en cuatro grupos: GI (sin adyuvante); GII (sufentanil; 5,0 µg); GIII (morfina; 100 µg); y GIV (clonidina; 75 µg). Se evaluaron: el inicio y el nivel de bloqueo sensitivo; analgesia peroperatoria; el grado y el tiempo para la regresion del bloqueo motor; la duracion de la analgesia; la sedacion; y las repercusiones materno-fetales. RESULTADOS: El inicio del bloqueo fue significativamente menor en los grupos con adyuvantes en comparacion con el Grupo I. En el perioperatorio, los pacientes de los Grupos I y III dijeron sentir dolor. La duracion de la analgesia fue significativamente mayor en el Grupo II y el tiempo para el desbloqueo motor fue significativamente mayor en el Grupo IV. El prurito aparecio en los grupos II y III. La sedacion fue significativa en el Grupo IV. La hipotension arterial se prolongo en el Grupo IV. CONCLUSIONES: La adicion de sufentanil y clonidina a la bupivacaina hiperbarica proporciono una adecuada anestesia para la cesarea como tambien una buena analgesia postoperatoria. La clonidina causo mas sedacion perioperatoria y un mayor tiempo para el desbloqueo motor. El prurito fue evidente cuando se usaron los opioides.