Letteratura scientifica selezionata sul tema "Anesthetics in obstetrics"

Background. Anesthesia should be selected individually for each labor. Systemic analgesia of labor includes suggestive analgesia, narcotic analgesics, local infiltration and regional blockade, inhalation analgesia. It should be noted that there is no analgesic, sedative or local anesthetic that does not penetrate the placenta, affecting the fetus in any way.
 Objective. To describe modern anesthesia in obstetrics.
 Materials and methods. Analysis of literature sources on this issue.
 Results and discussion. Three groups of antispasmodics are used for analgesia: neurotropic (atropine, scopolamine), myotropic (papaverine, drotaverine) and neuromyotropic (baralgin). The main non-steroidal anti-inflammatory drugs used for this purpose include metamizole sodium, ketorolac tromethamine, diclofenac sodium. Inhalation autoanalgesia with nitrous oxide (N2O) is effective only in 30-50 % of women. When the concentration of N2O exceeds 50 %, the sedative effect increases and oxygenation decreases, which leads to the loss of consciousness and protective laryngeal reflexes. Such analgesia is indicated for low-risk patients who have refused from regional anesthesia. Epidural anesthesia (EDA) is the gold standard of labor anesthesia. The advantages of EDA include the option to change the degree of analgesia, the ability to continue pain relief until the end of labor and the minimal impact on the condition of both child and mother. Before manipulation, be sure to determine the platelet count and heart rate of the fetus. It is recommended to start EDA in the latent stage of labor. In patients with uterine scarring, early EDA is a mandatory component of medical care. The woman’s wish is the main indication for EDA. Indications for early catheterization of the epidural space include the presence of twins, preeclampsia, obesity, respiratory tract with special features. Headache is the most common complication of EDA. The use of pencil-point spinal needles minimizes the frequency of this complication. Adequate analgesia for uncomplicated labor should be performed with minimal concentrations of anesthetics with the least possible motor block. Local anesthetics (lidocaine, bupivacaine (Longocaine, “Yuria-Pharm”), ropivacaine) are used for EDA). Combined spinal-epidural anesthesia provides a rapid effect and long-term analgesia. For this purpose, 0.25 % Longocaine heavy (“Yuria-Pharm”) 2 mg and fentanyl 20 μg are administered intrathecally, followed by 0.225 % Longocaine 10 mg and fentanyl 20 μg epidurally. The technique of epidural dural puncture is a modification of combined spinal-epidural anesthesia. This technique improves the caudal spread of analgesia compared to the epidural technique without the side effects seen with spinal-epidural anesthesia. The ideal local anesthetic should be safe for both mother and fetus, provide sufficient analgesia with minimal motor block, and not affect labor process. A single spinal injection of opioids may be effective, but it should be limited in time. The use of systemic opioids during labor increases the need for resuscitation of newborns and worsens the condition of their acid-base balance compared to basic regional anesthesia. Catheter techniques can be used in case of the increased labor duration. Nalbuphine (“Yuria-Pharm”), which eliminates the side effects of regional anesthesia, can also be successfully used. Analgesic effect of paracetamol (Infulgan, “Yuria-Pharm”) in case of intravenous administration exceeds the analgetic effect of tramadol, and the effect on the newborn condition according to the Apgar scale does not differ (Meenakshi et al., 2015). Paracetamol (Infulgan) is moderately effective for perineal pain on the first day after delivery. The possibility of use during lactation is an another advantage of paracetamol.
 Conclusions. 1. Pain during labor is an extremely stressful factor, so women should have access to quality analgesia and anesthesia. 2. There is no analgesic, sedative or local anesthetic that does not penetrate the placenta, affecting the fetus. 3. EDA is the gold standard of labor anesthesia. 4. Combined spinal-epidural anesthesia provides rapid effect and long-term analgesia. 5. The use of systemic opioids during labor increases the need for resuscitation of newborns and worsens the condition of their acid-base balance. 6. Nalbuphine and Infulgan have been used successfully for labor pain relief.

Background: Local anesthetics (LAs) are commonly used in obstetrics and gynecology (OB-GYN); however, inappropriate administration can cause local anesthetic systemic toxicity (LAST), a life-threatening condition. For safe medical practice, healthcare providers should carefully follow the guidelines for administering LAs for early identification and proper management of LAST when it occurs. Methods: This nationwide study used a 36-item self-administered questionnaire administered to healthcare professionals in OB-GYN and anesthesiology. The survey assessed the knowledge, attitudes, and practices of commonly used LA agents, their appropriate dosage, and awareness of LAST’s management. Results: A study of 391 Saudi healthcare professionals, between OB-GYN (51.2%) and anesthesiology (48.8%), reported greater engagement in anesthetic training and usage among anesthesiologists (88% trained, 58.1% daily use) than among OB-GYNs (38.5% trained, 30.5% daily use). OB-GYNs most commonly performed perineal tear repairs (88.5%), whereas anesthesiologists mainly performed paracervical blocks (89.5%). Lidocaine was the preferred local anesthetic for OB-GYNs at 93.5%, with anesthesiologists also favoring lidocaine but showing a higher use of bupivacaine (75.4%). Furthermore, the knowledge, attitudes, and practices scores of OB-GYN participants were significantly lower scores in all parameters compared to the anesthesiology participants (P < 0.001). Conclusions: Healthcare professionals in OB-GYN lack adequate knowledge of the safe and effective use of LA agents. Their knowledge must be increased through education to ensure safe practices.

Labour pain is recognized by some women as the most severe pain that they have ever felt in their life. Epidural analgesia is an effective method of pain relief in labour and is considered as the gold standard of analgesia for delivery. Traditionally, epidural analgesia in Ukraine is performed without the ability for the patient to control the process of anesthesia. The authors became interested in the delivery of local anesthetics by patient­controlled epidural analgesia instead of the traditional physician methods. In randomized controlled studies there is an evidence that the PCEA method tends to improve the quality of pain relief and increase the patient satisfaction.

Background. Sedation is a controlled medical depression of consciousness with the preservation of protective reflexes, independent effective breathing and response to physical stimulation and verbal commands. Requirements for sedation include rapid onset of effect, short action, minimal impact on the cardiorespiratory system, lack of delirium and emetic effect. The goals of sedation include patient comfort, minimization of pain and discomfort, anxiolysis, amnesia, control of patient behavior, rapid recovery.
 Objective. To describe the features of sedation in obstetrics and gynecology.
 Materials and methods. Analysis of literature data on this topic; own research. The study included 64 women with gynecological diseases who underwent elective surgery under regional anesthesia. Longocaine and Longocaine Heavy (“Yuria-Pharm”) were used as local anesthetics. Sedation by dexmedetomidine ("Yuria-Pharm") was used in group 1, and by propofol in group 2.
 Results and discussion. Cesarean section is characterized by high levels of stress. The main requirements for sedation during caesarean section include the preservation of consciousness, self-breathing and protective reflexes of the respiratory tract, minimal impact on hemodynamics, short duration of action of drugs. Subjective methods (different scales, verbal contact with the patient, assessment of pupil dilation, pulse, respiratory rate, blood pressure) and objective methods (electroencephalography, BIS spectral index) are used to determine the degree of sedation. Mandatory monitoring during sedation includes non-invasive blood pressure measurement, pulse oximetry, electrocardiography, capnography, BIS monitoring. Capnography is the most effective type of monitoring. For the safety of procedure carefully trained personnel, the device for mechanical lung ventilation, a set for ensuring passability of respiratory tracts, a defibrillator, and drugs for emergency medical care are necessary. For procedural sedation, drugs such as propofol, barbiturates, benzodiazepines, dexmedetomidine, ketamine, and inhalation anesthetics are used. The advantages of benzodiazepines are rapid effect and amnestic action, the disadvantages include the promotion of delirium and respiratory depression, no analgesic effect. The last two effects are also typical for propofol, which also causes pain in the vein during administration and the propofol infusion syndrome. The advantages of propofol include rapid onset of effect and rapid awakening, ease of titration, amnestic and antiemetic action. Ketamine also provides a rapid onset of effect and rapid awakening, and has an analgesic effect, however, causes hallucinations and hypersalivation, increased motor activity. Dexmedetomidine is an analgesic, has a sedative effect and a minimal effect on respiratory status. Disadvantages of dexmedetomidine include slow onset of effect and dose-dependent decrease in blood pressure. A number of scientific studies indicate the absence of adverse effects of dexmedetomidine during cesarean section under regional anesthesia. According to our own study, sedation with dexmedetomidine caused hypotension 26.5 % less often than sedation with propofol. Targeted sedation with dexmedetomidine caused almost no respiratory depression, whereas sedation with propofol led to moderate hypoxemia in 21 % of patients and severe hypoxemia in 35.9 % of patients. Dexmedetomidine contributed to a more pronounced reduction in pain, which can be explained by its own analgesic effect.
 Conclusions. 1. The goals of sedation include patient comfort, minimization of pain and discomfort, anxiolysis, amnesia, control of patient behavior, rapid recovery. 2. The main requirements for sedation during caesarean section include the preservation of consciousness, independent breathing and protective reflexes of the respiratory tract, minimal impact on hemodynamics, short duration of action of drugs. 3. Capnography is the most effective type of monitoring during sedation. 4. Sedation with dexmedetomidine caused hypotension 26.5 % less often than sedation with propofol. 5. Targeted sedation with dexmedetomidine caused almost no respiratory depression. 6. Dexmedetomidine contributed to a more pronounced reduction in pain than propofol.