Katsuo Terui

Delayed respiratory depression associated with 0.15 mg intrathecal morphine for cesarean section: a review of 1915 cases

PurposeA low dose of morphine, given intrathecally is an effective postoperative analgesic technique and is widely used in cesarean section. Delayed respiratory depression is the most feared side effect of this technique. However, this side effect has not been thoroughly reported in the obstetric population. The aim of this study was to describe respiratory depression associated with intrathecal morphine in postcesarean women, and to estimate its incidence.MethodsWe retrospectively reviewed the obstetric anesthesia database at our institution from April 2000 to December 2006. Patients who were given 0.15 mg intrathecal morphine for cesarean section were identified. From this group, we identified patients who developed bradypnea (respiratory rate ≤ 10 breaths·min−1) within 24 h after the intrathecal injection.ResultsOf 1915 women given 0.15 mg intrathecal morphine for postcesarean analgesia, 6 patients exhibited bradypnea within 24 h after the injection of morphine. Four of these 6 patients developed mild respiratory depression, which was treated with supplemental oxygen and/or encouragement of breathing. One patient had severe respiratory depression, and repeated episodes of oxygen desaturation below 90% and 30-s apneas were noted. Naloxone was required for this patient. One woman had obstructive sleep apnea which was not associated with the intrathecal morphine.ConclusionOf 1915 patients, 5 women (0.26%) developed bradypnea associated with 0.15 mg intrathecal morphine. The incidence of severe bradypnea requiring naloxone was 1/1915 (0.052%).

Pre‐delivery fibrinogen predicts adverse maternal or neonatal outcomes in patients with placental abruption

Placental abruption is a severe obstetric complication of pregnancy that can cause disseminated intravascular coagulation and progress to massive post‐partum hemorrhage. Coagulation disorder due to extreme consumption of fibrinogen is considered the main pathogenesis of disseminated intravascular coagulation in patients with placental abruption. The present study sought to determine if the pre‐delivery fibrinogen level could predict adverse maternal or neonatal outcomes in patients with placental abruption.

Randomized double‐blind comparison of the effects of intramyometrial and intravenous oxytocin during elective cesarean section

Obstetricians sometimes administer intramyometrial oxytocin to stimulate uterine contraction during cesarean section, but its effects have not been well investigated. We performed a randomized, double‐blind study to test the hypothesis that a small dose of intramyometrial oxytocin would induce acceptable uterine contractility more quickly and with fewer hemodynamic side‐effects than the same dose administered intravenously.

Japanese Clinical Practice Guide for Critical Obstetrical Hemorrhage (2017 revision)

Satoru Takeda, Shintaro Makino, Jun Takeda, Naohiro Kanayama, Takahiko Kubo, Akihito Nakai, Shunji Suzuki, Hiroyuki Seki, Katsuo Terui, Shoichi Inaba and Shigeki Miyata Japan Society of Obstetrics and Gynecology, Japan Association of Obstetricians and Gynecologists, Japan Society of Perinatal and Neonatal Medicine, Japanese Society of Anesthesiologists, Japan Society of Transfusion Medicine and Cell Therapy, Shirota Clinic, Department of Obstetrics and Gynecology, Juntendo University, Department of Obstetrics and Gynecology, Nippon Medical School Tama Nagayama Hospital, and Japanese Red Cross Katsushika Maternity Hospital, Tokyo, The Japanese Red Cross Kanto‐Koshinetsu Cord Blood Bank, Kanagawa, Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, Shizuoka, Departments of Obstetrics and Gynecology, Anesthesia, Saitama Medical Center, Saitama, and Division of Transfusion Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan

Outcomes of labor epidural analgesia among women aged over 40: A single-institution retrospective study.

The purpose of this study was to investigate the effects of labor epidural analgesia (LEA) on maternal and neonatal outcomes among parturients aged 40 years or older.

Reply to: Acute kidney injury in parturients with severe preeclampsia

We would like to appreciate the readers of this journal for their comments on our article [1]. As they mentioned, we did not have a control group, because we have been using hydroxyethyl starch (HES) to almost all cesarean delivery cases including severe preeclampsia over a decade. A prospective study for elucidating the effect of HES on postoperative kidney function of severe preeclampsia comparing with crystalloid would be preferable; however, several difficulties for assessing the outcomes would exist. First of all, as extremely rare incidence of acute kidney injury (AKI) during pregnancy [2], surrogate outcomes instead of the incidence of AKI would be preferable and feasible for conducting a clinical research. Dantzmann and associates reported that optimal surrogate biomarkers for investigating the effect of HES on AKI in perioperative setting have not been detected [3]. In preeclampsia, podocyte injury is considered as a main focus of renal impairment [4], but the association between HES administration and podocyte injury has not been investigated well. Moreover, as we discussed about glomerular filtration rate (GFR) during pregnancy, it did not indicate “estimated” GFR. Since estimated GFR is not reliable in pregnant women, we did not report estimated GFR in the study. Finally, although the main purpose of administrating HES instead of crystalloid with fluid restriction is for preventing iatrogenic pulmonary edema, we have not figured out the clinically reliable and measurable definition of perioperative pulmonary complications. A lung ultrasound assessment has been accumulating the evidence for diagnosing pulmonary edema, especially in emergency medicine [5, 6]. We are considering to shifting the novel diagnostic tool with sharply accurate and clinically feasible assessment in both daily practice and clinical research.

A systematic review of massive transfusion protocol in obstetrics

Post-partum obstetric haemorrhage is a leading cause of mortality among Japanese women, generally treated with haemostatic measures followed by supplementary transfusion. Commonly used in the setting of severe trauma, massive transfusion protocols (MTPs), preparations of red blood cell concentrate (RBC) and fresh frozen plasma (FFP) with additional supplements, have proved effective in decreasing patient mortality following major obstetric bleeding events. Although promising, the optimal configuration of RBC and FFP utilized for obstetric bleeding needs to be verified. Here, we conducted a systematic literature review to define the optimal ratio of RBC to FFP for transfusion therapy during instances of obstetric bleeding. Our analysis extracted four retrospective, observational studies, all demonstrating that an FFP/RBC ratio of ≥1 was associated with improved patient outcomes following obstetric haemorrhage. We therefore conclude that, from the standpoint of haemostatic resuscitation, an FFP/RBC ratio of ≥1 is a necessary condition for optimal clinical management during MTP administration in the field of obstetrics. Hence, we further propose an optimized MTP strategy to be utilized in the setting of severe obstetric bleeding.

Success rate and challenges of fetal anesthesia for ultrasound guided fetal intervention by maternal opioid and benzodiazepine administration

Objective: The safe and effective methods of fetal anesthesia/analgesia during ultrasound guided direct fetal procedure are yet to be determined. The authors investigated whether maternal diazepam/fentanyl administration meets this purpose. Methods: The medical/anesthesia records were retrospectively reviewed in cases between 2001 and 2010 at a tertiary perinatal center. Success rate as well as maternal and fetal complications were analysed. Results: Among the 150 procedures in 118 fetuses, diazepam 10 mg and fentanyl 200 µg sufficiently prevented fetal movement upon the procedure in 56% of the procedures. Supplemental anesthetic agents such as nitrous oxide and propofol were needed in other cases. No serious maternal complication was noted, while fetal cardiac arrest/severe bradycardia was noted in three fetuses, one of which was successfully resuscitated by intracardiac adrenalin injection. Conclusions: Maternal diiazepam/fentanyl administration offered adequate fetal condition without significant maternal complications. Since these procedures are performed to treat severe fetal conditions, preparation for fetal resuscitation is also important.

Evidence-based Anesthesiology for ART

ABSTRACT Anesthesia for ART procedures have been provided by a variety of anesthetic methods including sedation, regional anesthesia, and general anesthesia. Anesthetic management should be safe, and provide rapid recovery for those women undergoing procedures that are often performed on an ambulatory basis. During ART procedures, anesthetic agents are gradually transferred into follicular fluid. Laboratory studies have suggested that local anesthetic agents, nitrous oxide, volatile halogenated agents, and some intravenous agents, such as propofol, interfere with some aspects of reproductive physiology in vitro. However, there is little clinical data suggesting that brief administration of any of the currently used anesthetic agents for ART procedures adversely affect live birth rates. The concern for antiemetics and NSAIDS use around ART procedures warrants further study. Identification of agents and techniques that provide optimal analgesia or anesthesia with negligible impact on ART success remains an important task for anesthesiologists.