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Ko E, Choi SU, Lee J, Choi ES, Park YS. Exploring the Utility of remimazolam in cesarean sections under general anesthesia: A preliminary retrospective analysis and Implications for future study. Heliyon 2024; 10:e28485. [PMID: 38596107 PMCID: PMC11002043 DOI: 10.1016/j.heliyon.2024.e28485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 02/28/2024] [Accepted: 03/20/2024] [Indexed: 04/11/2024] Open
Abstract
Background Remimazolam has recently been introduced as a maintenance agent for general anesthesia. However, the effect of remimazolam on peripartum prognosis has not been reported. Therefore, this study aimed to compare the effects of remimazolam and propofol for uterotonic drugs following cesarean section. Methods The electronic medical records of 51 adult women who underwent elective cesarean sections by single obstetrician under general anesthesia were collected. Participants were categorized into two groups: the propofol group and the remimazolam group. General anesthesia was maintained by continuous infusion of propofol or remimazolam after delivery. The number of uterotonic drugs administered during the cesarean section, the estimated blood loss (EBL), and length of hospital stay (LOS) after delivery were assessed. Results Of the 51 patients included in the study, 35 were in the propofol group and 16 in the remimazolam group. In the remimazolam group, five patients (31.3%, 5/16) received more uterotonics than the standard regimen. Conversely, in the propofol group, 19 patients (54.3%, 19/35) were injected with more uterotonics than the standard regimen. Logistic regression analysis showed that abnormal positioning of the placenta (P = 0.079) and not using remimazolam (P = 0.100) were the most relevant factors associated with the increased use of uterotonics. There was no significant difference in EBL between the two groups. The use of remimazolam was clinically relevant with a shorter LOS (P = 0.059). Conclusions The use of remimazolam as a maintenance agent did not result in significantly higher use of intrapartum uterotonics compared to the use of propofol. These results cannot exclude all adverse effects of remimazolam during cesarean delivery. Further randomized controlled trials must be conducted to obtain high-quality evidence.
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Affiliation(s)
- Eunji Ko
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, South Korea
| | - Sung Uk Choi
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, South Korea
| | - Jaehee Lee
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, South Korea
| | - Eun-Saem Choi
- Department of Obstetrics and Gynecology, Korea University Anam Hospital, Seoul, South Korea
| | - Yoon Sun Park
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, South Korea
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Metodiev Y, Iliff HA, Sharif B, Bell SF, Oliver C, de Lloyd L. ObsTIVA-UK: a service evaluation of obstetric total intravenous anaesthesia in the United Kingdom. Anaesth Rep 2024; 12:e12293. [PMID: 38720816 PMCID: PMC11078484 DOI: 10.1002/anr3.12293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2024] [Indexed: 05/12/2024] Open
Abstract
We conducted a prospective observational service evaluation across the United Kingdom on the use of total intravenous anaesthesia (TIVA) for obstetric surgery between November 2022 and June 2023. The primary aim was to describe the incidence of TIVA for obstetric surgery within participating units, with secondary aims to describe maternal and neonatal postoperative recovery indicators. Of 184 maternity units in the United Kingdom, 30 (16%) contributed data to the service evaluation. There were 104 patients who underwent caesarean delivery under TIVA and 19 patients had TIVA for other reasons. Infusions of propofol and remifentanil were used in 100% and 84% of cases, respectively. Fifty-nine out of 103 live neonates (57%) required some form of respiratory support. Of the neonates with recorded data, 73% and 17% had Apgar scores < 7 at 1 and 5 min respectively. No neonates were recorded to have Apgar scores < 7 at 10 min. Further prospective research is required to investigate the impact of obstetric TIVA on maternal and neonatal outcomes and inform best practice recommendations.
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Affiliation(s)
- Y. Metodiev
- Department of AnaesthesiaUniversity Hospital of WalesCardiffUK
- School of MedicineCardiff UniversityCardiffUK
| | - H. A. Iliff
- Department of AnaesthesiaUniversity Hospital of WalesCardiffUK
| | - B. Sharif
- Department of AnaesthesiaUniversity Hospital of WalesCardiffUK
| | - S. F. Bell
- Department of AnaesthesiaUniversity Hospital of WalesCardiffUK
- School of MedicineCardiff UniversityCardiffUK
| | - C. Oliver
- Department of AnaesthesiaUniversity Hospital of WalesCardiffUK
| | - L. de Lloyd
- Department of AnaesthesiaUniversity Hospital of WalesCardiffUK
- School of MedicineCardiff UniversityCardiffUK
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Metodiev Y, Lucas D. The role of total intravenous anaesthesia for caesarean delivery. Int J Obstet Anesth 2022; 51:103548. [DOI: 10.1016/j.ijoa.2022.103548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/23/2022] [Accepted: 04/04/2022] [Indexed: 11/27/2022]
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Lee HA, Kawakami H, Mihara T, Sato H, Goto T. Impact of anesthetic agents on the amount of bleeding during dilatation and evacuation: A systematic review and meta-analysis. PLoS One 2021; 16:e0261494. [PMID: 34937059 PMCID: PMC8694452 DOI: 10.1371/journal.pone.0261494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 12/02/2021] [Indexed: 11/20/2022] Open
Abstract
Purpose Patients undergo dilatation and evacuation for abortion or miscarriage. However, bleeding is sometimes problematic. Despite reports on the association between volatile anesthetics and increased bleeding during the procedure, firm evidence is lacking. Therefore, we conducted a systematic review and meta-analysis to compare the effects of volatile anesthetics and propofol on the amount of bleeding in patients undergoing dilatation and evacuation. Methods We conducted a systematic search of four databases, namely PubMed, Embase, Cochrane Central Register of Controlled Trials databases, and Web of Science (Clarivate Analytics), from their respective inception to April 2021. Moreover, we searched two trial registration sites. The inclusion criterion was randomized controlled trials of patients who underwent dilatation and evacuation under general anesthesia using volatile anesthetics or propofol. The primary outcome was the amount of perioperative bleeding. The mean difference of the bleeding was combined using a random-effects model. The I2 statistic was used to assess heterogeneity. We assessed risk of bias with Cochrane domains. We controlled type I and II errors due to sparse data and repetitive testing with Trial Sequential Analysis. We assessed the quality of evidence with GRADE. Results Five studies were included in the systematic review. The amount of bleeding was compared in four studies and was higher in the volatile anesthetic group, with a mean difference of 164.7 ml (95% confidence interval, 43.6 to 285.7; p = 0.04). Heterogeneity was considerable, with an I2 value of 97%. Two studies evaluated the incidence of significant bleeding, which was significantly higher in the volatile anesthetic group (RR, 2.42; 95% confidence interval, 1.04–5.63; p = 0.04). Conclusion Choosing propofol over volatile anesthetics during dilatation and evacuation might reduce bleeding and the incidence of excessive bleeding. However, the quality of the evidence was very low. This necessitates further trials with a low risk of bias. Trial registration PROSPERO (CRD42019120873).
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Affiliation(s)
- Hyun Ah Lee
- Intensive Care Unit, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Hiromasa Kawakami
- Operation Department, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
- * E-mail:
| | - Takahiro Mihara
- Department of Anesthesiology, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Hitoshi Sato
- Department of Anesthesiology, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Takahisa Goto
- Department of Anesthesiology, Yokohama City University Hospital, Yokohama, Kanagawa, Japan
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Kimizuka M, Tokinaga Y, Azumaguchi R, Hamada K, Kazuma S, Yamakage M. Effects of anesthetic agents on contractions of the pregnant rat myometrium in vivo and in vitro. J Anesth 2021; 35:68-80. [PMID: 33098452 PMCID: PMC7840642 DOI: 10.1007/s00540-020-02866-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 10/08/2020] [Indexed: 10/31/2022]
Abstract
BACKGROUND Several anesthetic agents are used in cesarean sections for both regional and general anesthesia purposes. However, there are no data comparing the in vivo effects of propofol, sevoflurane, and dexmedetomidine on the contraction of the myometrium in pregnant rats. The aim of this study was to investigate the effect of these anesthetic agents on myometrial contraction and elucidate the underlying mechanisms. METHODS Contraction force and frequency changes in response to propofol, dexmedetomidine, or sevoflurane were evaluated in vivo and in vitro. To test the effect of arachidonic acid on myometrial contraction enhanced by dexmedetomidine, changes in myometrial contraction with dexmedetomidine after administration of indomethacin were evaluated. The amount of phosphorylated myosin phosphatase target subunit 1 (MYPT1) in the membrane fraction was expressed as a percentage of the total fraction by Western blot analysis. RESULTS This study demonstrated that dexmedetomidine enhances oxytocin-induced contraction in the myometrium of pregnant rats, whereas propofol and sevoflurane attenuate these contractions. The dexmedetomidine-induced enhancement of myometrial contraction force was abolished by the administration of indomethacin. Propofol did not affect oxytocin-induced MYPT1 phosphorylation, whereas sevoflurane attenuated oxytocin-induced MYPT1 phosphorylation. CONCLUSIONS Inhibition of myofilament calcium sensitivity may underlie the inhibition of myometrial contraction induced by sevoflurane. Arachidonic acid may play an important role in the enhancement of myometrial contraction induced by dexmedetomidine by increasing myofilament calcium sensitivity. Dexmedetomidine may be used as a sedative agent to promote uterine muscle contraction and suppress bleeding after fetal delivery.
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Affiliation(s)
- Motonobu Kimizuka
- Department of Anesthesiology, Sapporo Medical University School of Medicine, 291, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan.
| | - Yasuyuki Tokinaga
- Department of Anesthesiology, Sapporo Medical University School of Medicine, 291, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Ryu Azumaguchi
- Department of Anesthesiology, Sapporo Medical University School of Medicine, 291, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Kosuke Hamada
- Department of Anesthesiology, Sapporo Medical University School of Medicine, 291, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Satoshi Kazuma
- Department of Anesthesiology, Sapporo Medical University School of Medicine, 291, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, Sapporo Medical University School of Medicine, 291, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
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Wang Y, Gao H, Bao T, Yang L, Ding G, Ba D, Sun S, Lin Y, Yao S. Ethnic disparities in postpartum hemorrhage after cesarean delivery: a retrospective case-control study. J Anesth 2021; 35:197-205. [PMID: 33507393 PMCID: PMC7969550 DOI: 10.1007/s00540-021-02899-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 01/08/2021] [Indexed: 11/12/2022]
Abstract
Purpose To explore the relationship of ethnicity and postpartum hemorrhage (PPH) for women who underwent cesarean delivery (CD) and examine the risk factors for PPH in distinct ethnic groups in China. Methods We conducted case–control studies with the maternity data from the 11,778 CD cases, in Xinjiang Uygur Autonomous Region. Initially, multivariable logistic regression was used to estimate the disparity of race-ethnicity on the risk of PPH in ethnic Han, Uygur, Hui and Kazakh. Then, we performed case–control studies within two major ethnic groups, identifying the specific risk factors for PPH. Results Ethnic Uygur were associated with a statistically significant increased odds [adjusted odds ratios (aOR) 2.05; 95% confidence interval (CI) 1.26–3.33] of PPH compared with ethnic Han. For subgroup analyses, in Uygur subgroup, general anesthesia (aOR 7.78; 95% CI 2.31–26.20); placenta previa (aOR 11.18; 95% CI 3.09–40.45); prenatal anemia (aOR 4.84; 95% CI 2.44–9.60); emergency surgery (aOR 4.22; 95% CI 1.95–9.13) were independently associated with PPH. In Han subgroup, general anesthesia (aOR 5.70; 95% CI 1.89–17.26); placenta previa (aOR 20.08; 95% CI 6.35–63.46); multiple pregnancy (aOR 7.21; 95% CI 1.61–32.37); body mass index (aOR 1.19; 95% CI 1.07–1.31) were the risk factors to PPH. Conclusion Uygur have more tendency to PPH compared to Han, and risk factors for PPH in Uygur and Han groups may differ. Knowing these differences may be meaningful when planning interventions and resources for high-risk patients undergoing cesarean delivery, and we need more research aimed at risk factors for PPH.
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Affiliation(s)
- Yu Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hexin Gao
- Department of Anesthesiology, Maternal and Child Health Hospital of Xinjiang Uyghur Autonomous Region, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Tuvshin Bao
- Department of Anesthesiology, Inner Mongolia Maternal and Child Health Care Hospital, Hohhot, Inner Mongolia Autonomous Region, China
| | - Lijuan Yang
- Department of Anesthesiology, Maternal and Child Health Hospital of Xinjiang Uyghur Autonomous Region, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Guifeng Ding
- Department of Anesthesiology, Maternal and Child Health Hospital of Xinjiang Uyghur Autonomous Region, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Demu Ba
- Department of Anesthesiology, People's Hospital of Bozhou, Bole, Xinjiang Uygur Autonomous Region, China
| | - Shujun Sun
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun Lin
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Shanglong Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Wladarz J, Wenk M, Massoth C. Notsectio: eine Herausforderung in der geburtshilflichen Anästhesie. Anasthesiol Intensivmed Notfallmed Schmerzther 2020; 55:662-673. [PMID: 33242900 DOI: 10.1055/a-1070-6810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Marsh BJ, Sinskey J, Whitlock EL, Ferschl MB, Rollins MD. Use of Remifentanil for Open in utero Fetal Myelomeningocele Repair Maintains Uterine Relaxation with Reduced Volatile Anesthetic Concentration. Fetal Diagn Ther 2020; 47:810-816. [PMID: 32911467 DOI: 10.1159/000509384] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 06/09/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Open fetal repair of myelomeningocele (MMC) is an option for prenatally diagnosed spina bifida. Historically, high-dose volatile anesthetic was used for uterine relaxation but is associated with fetal cardiovascular depression. We examined the impact of administering a supplemental remifentanil infusion on the concentration of inhaled anesthetic required for intraoperative uterine relaxation. METHODS We retrospectively analyzed 22 consecutive patients who underwent open fetal MMC repair with desflurane anesthesia from 2014 to 2018. The anesthetic protocol was modified to include high-dose opioid with remifentanil in 2016. We examined intraoperative end-tidal desflurane concentrations, vasopressor use, incidence of umbilical artery Doppler abnormalities, and incidence of preterm labor and delivery. RESULTS Patients (n = 11) who received desflurane and remifentanil (Des/Remi) were compared to patients (n = 11) who received desflurane (Des) alone. Intraoperatively, the maximum end-tidal desflurane required to maintain uterine relaxation was lower in the Des/Remi group (7.9 ± 2.2% vs. 13.1 ± 1.2%, p < 0.001). The mean phenylephrine infusion rate was also lower in the Des/Remi group (36 ± 14 vs. 53 ± 10 mcg/min, p = 0.004). DISCUSSION Use of opioid with supplemental remifentanil was associated with lower volatile anesthetic dosing and decreased vasopressor use; fetal outcomes were not different. Remifentanil may allow for less volatile anesthetic use while maintaining adequate uterine relaxation.
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Affiliation(s)
- Benjamin J Marsh
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, USA
| | - Jina Sinskey
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, USA
| | - Elizabeth L Whitlock
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, USA
| | - Marla B Ferschl
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, USA,
| | - Mark D Rollins
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Yoshimura M, Kunisawa T, Suno M, Sugawara A, Kurosawa A, Nakanishi R, Aoki K, Toriumi T. Intravenous dexmedetomidine for cesarean delivery and its concentration in colostrum. Int J Obstet Anesth 2017; 32:28-32. [DOI: 10.1016/j.ijoa.2017.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 04/18/2017] [Accepted: 05/04/2017] [Indexed: 01/23/2023]
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Sumikura H, Niwa H, Sato M, Nakamoto T, Asai T, Hagihira S. Rethinking general anesthesia for cesarean section. J Anesth 2015; 30:268-73. [DOI: 10.1007/s00540-015-2099-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 10/30/2015] [Indexed: 12/19/2022]
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Tawfik MM, Badran BA, Eisa AA, Barakat RI. Simultaneous cesarean delivery and craniotomy in a term pregnant patient with traumatic brain injury. Saudi J Anaesth 2015; 9:207-10. [PMID: 25829914 PMCID: PMC4374231 DOI: 10.4103/1658-354x.152890] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The management of pregnant patients with traumatic brain injury is challenging. A multidisciplinary team approach is mandatory, and management should be individualized according to the type and extent of injury, maternal status, gestational age, and fetal status. We report a 27-year-old term primigravida presenting after head injury with Glasgow coma scale score 11 and anisocoria. Depressed temporal bone fracture and acute epidural hematoma were diagnosed, necessitating an urgent neurosurgery. Her fetus was viable with no signs of distress and no detected placental abnormalities. Cesarean delivery was performed followed by craniotomy in the same setting under general anesthesia with good outcome of the patient and her baby.
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Affiliation(s)
- Mohamed Mohamed Tawfik
- Department of Anesthesia and Surgical Intensive Care, Mansoura University Hospitals, Mansoura, Daqahlia, Egypt
| | - Basma Abed Badran
- Department of Anesthesia and Surgical Intensive Care, Mansoura University Hospitals, Mansoura, Daqahlia, Egypt
| | - Ahmed Amin Eisa
- Department of Anesthesia and Surgical Intensive Care, Mansoura University Hospitals, Mansoura, Daqahlia, Egypt
| | - Rafik Ibrahim Barakat
- Department of Obstetrics and Gynecology, Mansoura University Hospitals, Mansoura, Daqahlia, Egypt
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Parant O, Guerby P, Bayoumeu F. Spécificités obstétricales et anesthésiques de la prise en charge d’une hémorragie du post-partum (HPP) associée à la césarienne. ACTA ACUST UNITED AC 2014; 43:1104-22. [DOI: 10.1016/j.jgyn.2014.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Affiliation(s)
- Yusuke Mazda
- Saitama Medical Center, Saitama Medical University; Division of Obstetric Anesthesia, Department of Anesthesiology; 1981 Kamoda Kawagoe Saitama Japan 350-8550
| | - Erika Ota
- National Center for Child Health and Development; Department of Health Policy; 2-10-1 Okura, Setagaya-ku Tokyo Japan 157-8535
| | - Rintaro Mori
- National Center for Child Health and Development; Department of Health Policy; 2-10-1 Okura, Setagaya-ku Tokyo Japan 157-8535
| | - Katsuo Terui
- Saitama Medical Center, Saitama Medical University; Division of Obstetric Anesthesia, Department of Anesthesiology; 1981 Kamoda Kawagoe Saitama Japan 350-8550
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Sherwin CMT, Ngamprasertwong P, Sadhasivam S, Vinks AA. Utilization of optimal study design for maternal and fetal sheep propofol pharmacokinetics study: a preliminary study. ACTA ACUST UNITED AC 2014; 9:64-9. [PMID: 24219004 DOI: 10.2174/1574884708666131111200417] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 03/27/2013] [Accepted: 03/29/2013] [Indexed: 11/22/2022]
Abstract
Multiple blood samples are generally required for measurement of pharmacokinetic (PK) parameters. D-optimal design is a popular and frequently used approach for determination of sampling time points in order to minimize the number of samples, while optimizing the estimation of PK parameters. Optimal design utilizing ADAPT (v5, BSR, University of Southern California, Los Angeles) developed a sparse sampling strategy to determine measurement of propofol in pregnant sheep. Propofal was administered as supplemental anesthetic agent to inhalation anesthesia to mimic anesthesia for open fetal surgery. In our preliminary study, propofol 3 mg/kg was given as a bolus to the ewe, followed by propofol infusion at rate 450 mcg/kg/min for 60 minutes, then decreased to 75 mcg/kg/min for 90 more minutes and then ceased. A three compartment model described the PK parameters with the fetus assumed as the third compartment. Initially, sampling times were chosen from thirteen time points as previously stated in the literature. Using priori propofol PK estimates, the final 9 sample time points were proposed in an optimal design with a change in infusion rate occurring between 65 and 75 minutes and sampling proposed at 5, 15, 25, 65, 75, 100, 110, 150, and 180 minutes. D-optimal design optimized the number and timing of samplings, which led to a reduction of cost and man power in the study protocol while preserving the ability to estimate propofol PK parameters in the maternal and fetal sheep model. Initial evaluation of samples collected from three sheep using the optimal design strategy confirmed the performance of the design in obtaining effective PK parameter estimates.
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Affiliation(s)
| | | | | | - Alexander A Vinks
- Clinical Anesthesia and Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH 45229, USA.
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HEESEN MICHAEL, HOFMANN THOMAS, KLÖHR SVEN, ROSSAINT ROLF, VAN DE VELDE MARC, DEPREST JAN, STRAUBE SEBASTIAN. Is general anaesthesia for caesarean section associated with postpartum haemorrhage? Systematic review and meta-analysis. Acta Anaesthesiol Scand 2013; 57:1092-102. [PMID: 24003971 DOI: 10.1111/aas.12178] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postpartum haemorrhage (PPH) remains a leading cause of maternal morbidity and mortality. The odds for PPH were about eight times higher following general anaesthesia compared with neuraxial anaesthesia in a recent retrospective study. We aimed to conduct a systematic review and meta-analysis of the effect of type of anaesthesia (general vs. neuraxial) on estimated blood loss and transfusion requirements after caesarean section. METHODS A systematic literature search was performed. The quality of eligible reports was assessed using the Oxford Quality Scale. Data were subjected to meta-analysis using the random effects model. RESULTS The search identified 18 articles including 12,330 parturients. Meta-analysis of randomised controlled trials (RCTs) found a significant difference in blood loss, favouring neuraxial anaesthesia (spinal and epidural) when comparing with general anaesthesia {weighted mean difference -106.11 ml [95% confidence interval (CI) -209.80, -2.42 ml], P = 0.04}. In further analyses, we found a significant difference after epidural compared with general anaesthesia but not after spinal compared with general anaesthesia. Based on RCTs, there was no significantly increased risk of blood transfusions with general anaesthesia. Analysis of non-randomised studies found a significantly higher transfusion requirement after general anaesthesia (risk ratio 5.06, 95% CI 2.47-10.36, P < 0.00001). The incidence of hypotension and the amount of fluid given were higher in the neuraxial anaesthesia groups. CONCLUSION General anaesthesia is associated with a higher blood loss than neuraxial anaesthesia. However, based on high-quality studies, the need for blood transfusion was not greater. The higher blood loss with general anaesthesia is therefore of uncertain clinical relevance.
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Affiliation(s)
- MICHAEL HEESEN
- Department of Anaesthesia; Klinikum Bamberg; Bamberg; Germany
| | - THOMAS HOFMANN
- Department of Anaesthesia; Klinikum Bamberg; Bamberg; Germany
| | - SVEN KLÖHR
- Department of Anaesthesia; Klinikum Bamberg; Bamberg; Germany
| | - ROLF ROSSAINT
- Department of; Anaesthesia; University Hospital Aachen; Aachen; Germany
| | - MARC VAN DE VELDE
- Department of Anaesthesia; Universitair Zieckenhuis Leuven; Leuven; Belgium
| | - JAN DEPREST
- Department of Gynecology; Universitair Zieckenhuis Leuven; Leuven; Belgium
| | - SEBASTIAN STRAUBE
- Institute of Occupational; Social and Environmental Medicine; University Medical Center Göttingen; Göttingen; Germany
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Ngamprasertwong P, Vinks AA, Boat A. Update in fetal anesthesia for the ex utero intrapartum treatment (EXIT) procedure. Int Anesthesiol Clin 2012; 50:26-40. [PMID: 23047444 PMCID: PMC3756472 DOI: 10.1097/aia.0b013e31826df966] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The ex-utero intrapartum treatment (EXIT) is one type of fetal surgery, performed before delivery while the fetus remains attached to the uteroplacental circulation. This intervention improves neonatal morbidity and mortality of certain congenital diseases. For instance, securing the airway of a fetus with congenital airway obstruction while on uteroplacental circulation prevents the hypoxemia during the establishment of an airway post-delivery. Anesthesia for fetal surgery now incorporates new knowledge of the maternal/fetal response to anesthetic agents. This chapter reviews for the EXIT procedure the effects of maternal anesthesia on fetal hemodynamics, intravenous anesthesia to supplement inhalational anesthesia in order to provide maternal-fetal hemodynamic stability during surgery, intraoperative fetal monitoring, maternal pharmacokinetics approach to study placental drug transfer and fetal pharmacokinetics to improve our understanding of the effects of maternal anesthesia on the fetus.
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Affiliation(s)
- Pornswan Ngamprasertwong
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Anne Boat
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
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Chang CC, Wang IT, Chen YH, Lin HC. Anesthetic management as a risk factor for postpartum hemorrhage after cesarean deliveries. Am J Obstet Gynecol 2011; 205:462.e1-7. [PMID: 21939956 DOI: 10.1016/j.ajog.2011.06.068] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2010] [Revised: 03/28/2011] [Accepted: 06/13/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This population-based study aimed to compare the risk of postpartum hemorrhage (PPH) for patients who underwent cesarean section delivery (CS) with general vs spinal/epidural anesthesia. STUDY DESIGN We identified 67,328 women who had live singleton births by CS by linking the Taiwan National Health Insurance Research Dataset and the national birth certificate registry. Multivariate logistic regression was carried out to explore the relationship between anesthetic management type and PPH. RESULTS Women who received general anesthesia had a higher rate of PPH than women who received epidural anesthesia (5.1% vs 0.4%). The odds of PPH in women who had CS with general anesthesia were 8.15 times higher (95% confidence interval, 6.43-10.33) than for those who had CS with epidural anesthesia, after adjustment was made for the maternal and fetal characteristics. CONCLUSION The odds that women will experience cesarean PPH with general anesthesia are approximately 8.15 times higher than for women who undergo CS with epidural anesthesia.
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Boat A, Mahmoud M, Michelfelder EC, Lin E, Ngamprasertwong P, Schnell B, Kurth CD, Crombleholme TM, Sadhasivam S. Supplementing desflurane with intravenous anesthesia reduces fetal cardiac dysfunction during open fetal surgery. Paediatr Anaesth 2010; 20:748-56. [PMID: 20670239 DOI: 10.1111/j.1460-9592.2010.03350.x] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To lower the incidence and severity of fetal cardiovascular depression during maternal fetal surgery under general anesthesia. AIM We hypothesized that supplemental intravenous anesthesia (SIVA) with propofol and remifentanil would lower the need for high-dose inhalational anesthesia and provide adequate maternal depth of anesthesia and uterine relaxation. SIVA technique would minimize prolonged fetal exposure to deep inhalational anesthetics and significant intraoperative fetal cardiovascular depression. BACKGROUND Fetal hypoxia and significant fetal hemodynamic changes occur during open fetal surgery because of the challenges such as surgical manipulation, hysterotomy, uterine contractions, and effects of anesthetic drugs. Tocolysis, a vital component of fetal surgery, is usually achieved using volatile anesthetic agents. High concentrations of volatile agents required to provide an appropriate degree of uterine relaxation may cause maternal hypotension and placental hypoperfusion, as well as direct fetal cardiovascular depression. METHODS We reviewed medical records of 39 patients who presented for ex utero intrapartum treatment and mid-gestation open fetal surgery between April 2004 and March 2009. Out of 39 patients, three were excluded because of the lack of echocardiographic data; 18 patients received high-concentration desflurane anesthesia and 18 patients had SIVA with desflurane for uterine relaxation. We analyzed the following data: demographics, fetal medical condition, anesthetic drugs, concentration and duration of desflurane, maternal arterial blood pressure, intraoperative fetal echocardiogram, presence of fetal bradycardia, and need for intraoperative fetal resuscitation. RESULTS Adequate uterine relaxation was achieved with about 1.5 MAC of desflurane in the SIVA group compared to about 2.5 MAC in the desflurane only anesthesia group (P = 0.0001). More fetuses in the high-dose desflurane group compared to the SIVA group developed moderate-severe left ventricular systolic dysfunction over time intraoperatively (P = 0.02). 61% of fetuses in the high-dose desflurane group received fetal resuscitative interventions compared to 26% of fetuses in the SIVA group (P = 0.0489). CONCLUSION SIVA as described provides adequate maternal anesthesia and uterine relaxation, and it allows for decreased use of desflurane during open fetal surgery. Decreased use of desflurane may better preserve fetal cardiac function.
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Affiliation(s)
- Anne Boat
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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